2025 CPT code 58545
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Female Genital System Surgery Feed
Laparoscopic surgical myomectomy involving the excision of 1 to 4 intramural myomas weighing a total of 250 grams or less, with or without the removal of surface myomas.
Modifiers may be applicable depending on circumstances (e.g., 51 for multiple procedures, 59 for distinct procedural services, 22 for increased procedural services, etc.)
Medical necessity is established when symptoms such as menorrhagia, metrorrhagia, pelvic pain, pressure symptoms, infertility, or other significant clinical manifestations are directly attributable to uterine fibroids, and less invasive treatments have failed or are not suitable.
A gynecologist or other qualified surgeon performs this procedure. Responsibilities include patient evaluation, surgical planning, performing the laparoscopic myomectomy, managing any complications intraoperatively and postoperatively, and providing follow-up care. Anesthesiologist or Certified Registered Nurse Anesthetist (CRNA) provides anesthesia.
In simple words: This code describes a minimally invasive surgery to remove one to four fibroids (noncancerous growths in the uterus) using a small camera and instruments inserted through small cuts in the belly.The surgeon removes the fibroids, repairs the uterus, and closes the small incisions.
This CPT code encompasses laparoscopic surgical myomectomy, a procedure where 1 to 4 intramural uterine fibroids (myomas) with a combined weight of 250 grams or less are excised.The procedure may also include the removal of surface myomas.The laparoscopic approach involves small incisions in the abdomen, insertion of a laparoscope and specialized instruments, and the use of CO2 insufflation to distend the abdominal cavity for optimal visualization.Fibroids are carefully dissected from the uterine muscle, bleeding is controlled, and the uterine wall is repaired. The excised fibroids are typically morcellated (cut into smaller pieces) for easier removal through the trocar sites. The procedure concludes with closure of incisions.
Example 1: A 35-year-old woman presents with heavy menstrual bleeding and pelvic pain attributed to three intramural fibroids (total weight 200g). Laparoscopic myomectomy is performed to resect the fibroids., A 40-year-old woman with infertility and four small subserosal fibroids (total weight 150g) undergoes laparoscopic myomectomy to improve fertility potential., A 42-year-old patient with one large intramural fibroid (230g) and multiple smaller surface fibroids undergoes laparoscopic myomectomy to alleviate symptoms and preserve fertility.
* Preoperative evaluation including history, physical exam, imaging (ultrasound), and laboratory tests.* Operative report detailing the number, size, location, and weight of fibroids removed.* Pathology report confirming the benign nature of the removed tissue.* Postoperative orders and progress notes documenting the patient's recovery and any complications.* Consent form.
** The weight of the fibroids is crucial for correct code selection.This procedure may be performed using robotic assistance; however, this does not change the code.
- Revenue Code: P1G (MAJOR PROCEDURE - OTHER)
- Payment Status: Active
- Specialties:Obstetrics and Gynecology
- Place of Service:Ambulatory Surgical Center, Hospital Outpatient, Office