2025 CPT code 58291
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Female Genital System Surgery Feed
Vaginal hysterectomy for a uterus weighing over 250 grams, including removal of fallopian tubes and/or ovaries.
Modifiers may apply depending on the circumstances of the procedure. For example, modifier 51 may be used if multiple procedures are performed during the same session.
The medical necessity for this procedure is established by the presence of significant symptoms (heavy menstrual bleeding, pelvic pain, pressure) caused by a large uterus, often due to fibroids or other conditions. The size of the uterus exceeding 250g justifies the use of this specific code over other vaginal hysterectomy codes.
The physician performs the entire surgical procedure, including pre-operative assessment, anesthesia administration (or supervision), surgical technique, and post-operative care.
In simple words: This surgery removes the uterus, cervix, fallopian tubes, and possibly the ovaries through the vagina.It's used when the uterus is abnormally large, often from fibroids, and is done under general anesthesia.
This procedure involves the surgical removal of the uterus, cervix, fallopian tubes, and/or ovaries through the vagina.The uterus is larger than normal (over 250 grams), often due to fibroids. The procedure begins with the patient in the dorsal lithotomy position under general anesthesia.The physician examines the genital tract, inserts a weighted speculum, and injects a local anesthetic.The uterosacral and cardinal ligaments are incised near the cervix, and the uterosacral ligaments are sutured to the posterior vaginal wall for support.The bladder is freed from the anterior vaginal wall. The uterine arteries are clamped and cut, and the infundibulopelvic and round ligaments are severed to release the uterus. Due to the uterus's size, morcellation may be used to remove it in pieces. The vaginal cuff is closed with sutures, and the uterosacral ligaments are pleated to prevent bowel prolapse.
Example 1: A 45-year-old woman presents with heavy menstrual bleeding and pelvic pain, diagnosed with uterine fibroids causing a significantly enlarged uterus (over 250g). A vaginal hysterectomy with bilateral salpingo-oophorectomy (removal of fallopian tubes and ovaries) is performed using code 58291., A 50-year-old woman with a history of endometriosis undergoes a vaginal hysterectomy with removal of tubes and ovaries (code 58291) due to severe pelvic pain and a large, fibroid-filled uterus weighing more than 250 grams., A 38-year-old patient with a history of abnormal uterine bleeding and a large uterine fibroid undergoes a vaginal hysterectomy with the removal of the uterus, fallopian tubes, and ovaries (code 58291). Due to the size of the uterus, exceeding 250 grams, morcellation was necessary.
* Pre-operative history and physical examination including imaging studies (ultrasound, MRI) showing uterine size and fibroids.* Operative report detailing the surgical technique, including morcellation if performed.* Pathology report confirming the removal of the uterus, adnexa, and the nature of any pathology.* Post-operative progress notes documenting the patient's recovery and any complications.
** This code is specifically for vaginal hysterectomies where the uterus weighs more than 250 grams.If the uterus weighs 250 grams or less, other vaginal hysterectomy codes should be considered.The use of morcellation should be explicitly documented in the operative report.
- Revenue Code: P1E (MAJOR PROCEDURE - HYSTERECTOMY)
- Payment Status: Active
- Specialties:Obstetrics and Gynecology
- Place of Service:Office, Ambulatory Surgical Center, Inpatient Hospital