2025 CPT code 58546
(Active) Effective Date: N/A Surgery - Surgical Procedures on the Female Genital System Feed
Laparoscopic myomectomy for the removal of 5 or more intramural myomas or any number with a total weight greater than 250 grams.
Modifiers may be applicable to indicate specific circumstances like increased procedural services (22), multiple procedures (51), or other situations outlined in CPT guidelines.
Medical necessity for this procedure must be established by documenting the patient's symptoms (e.g., heavy bleeding, pelvic pain, infertility) and their impact on quality of life, along with failed attempts at conservative management, if any.
The surgeon's responsibilities include patient positioning, anesthesia administration, creating and maintaining pneumoperitoneum, dissecting and removing fibroids, controlling bleeding, repairing the uterus, and closing incisions.
In simple words: The doctor removes fibroid tumors from the uterus using a laparoscope (a thin tube with a camera).This is done through small cuts in the belly. The procedure is used when there are five or more fibroids inside the uterine wall, or when the fibroids weigh more than 250 grams in total.
This code describes a laparoscopic procedure where five or more intramural fibroids are removed, or any number of fibroids if their combined weight exceeds 250 grams. The procedure involves inserting a laparoscope and surgical instruments through small incisions in the abdomen. The fibroids are dissected, removed (often through morcellation), and the uterus is repaired.
Example 1: A 35-year-old woman with symptomatic uterine fibroids causing heavy menstrual bleeding and pelvic pressure is found to have six intramural fibroids during a preoperative ultrasound., A 42-year-old woman desires to preserve fertility and undergoes a laparoscopic myomectomy for four large intramural fibroids with a combined weight exceeding 250 grams., A patient presents with multiple large fibroids within the muscular wall of her uterus (intramural), causing significant pelvic pain. Due to their large size, laparoscopic surgery is used and morcellation is required for removal.
Documentation should include details about the size, number, and location of fibroids; operative report detailing the procedure; estimated blood loss; any complications; and confirmation of the total weight if applicable.
- Specialties:Gynecology, Obstetrics
- Place of Service:Ambulatory Surgical Center, Inpatient Hospital, Outpatient Hospital