2025 CPT code 58294
(Active) Effective Date: N/A Surgery - Surgical Procedures on the Female Genital System Surgery Feed
Vaginal hysterectomy for a uterus weighing greater than 250 grams with enterocele repair.
Modifiers may be applicable to indicate specific circumstances of the procedure, such as increased procedural services (22), multiple procedures (51), or other factors impacting the service provided. Refer to current modifier guidelines for appropriate usage.
Medical necessity must be established for both the hysterectomy and the enterocele repair.The documentation must support the clinical rationale for the procedure, linking the patient's symptoms and the medical condition to the need for the intervention. This might involve imaging studies, physical exam findings, and a clear description of the patient's symptoms.
The physician is responsible for the complete surgical procedure, including preoperative evaluation, anesthesia management, surgical technique, postoperative care, and management of complications.
In simple words: The doctor removes the uterus and cervix through the vagina. Because the patient's small intestine is bulging into the vagina (called an enterocele), this is also repaired. The uterus is larger than usual, weighing over 250 grams, likely due to fibroids.
This procedure involves the surgical removal of the uterus and cervix through the vagina, along with the repair of an enterocele (a herniation of the small intestine into the vagina). This code is specifically for uteri weighing more than 250 grams, often due to fibroids.The procedure typically includes ligation and transection of supporting ligaments, morcellation (removal in pieces) of the enlarged uterus, and closure of the vaginal cuff.
Example 1: A 45-year-old female presents with symptomatic uterine fibroids causing heavy menstrual bleeding and pelvic pressure. Her uterus is estimated to be greater than 250 grams. She also has an enterocele. A vaginal hysterectomy with enterocele repair (58294) is performed., A 50-year-old female with a prolapsed uterus and an enterocele undergoes vaginal hysterectomy with enterocele repair. The uterus is found to weigh 280 grams upon removal., A 55-year-old woman experiences pelvic discomfort and difficulty with bowel movements. Examination reveals an enterocele and a large uterus due to fibroids. A vaginal hysterectomy with concomitant enterocele repair is performed, and the uterus weighs over 250 grams.
Documentation should include the size and weight of the uterus, presence of fibroids, details of the enterocele repair, and any associated procedures. Operative reports and pathology reports are crucial for accurate coding.
** Accurate coding requires a thorough review of the operative report and supporting documentation to capture all aspects of the procedure. If the uterus weight is not explicitly stated but can be inferred to be greater than 250g based on documentation of large fibroids and difficulty removing the uterus vaginally, use code 58294.
- Revenue Code: P1E - MAJOR PROCEDURE - HYSTERECTOMY
- Payment Status: Active
- Specialties:Obstetrics and Gynecology, Urogynecology
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center