2025 CPT code 58554
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Female Genital System Surgery Feed
Laparoscopic-assisted vaginal hysterectomy for a uterus weighing more than 250 grams, with removal of fallopian tubes and/or ovaries.
Modifiers may apply depending on the circumstances of the procedure (e.g., 22 for increased procedural services, 59 for distinct procedural service). Consult the most recent CPT guidelines.
Medical necessity is established by symptoms such as menorrhagia, chronic pelvic pain, or pressure symptoms related to uterine fibroids or significant uterine enlargement.Pre-operative assessment, including imaging, should demonstrate the need for surgical intervention.
The clinical responsibility involves the surgeon performing a laparoscopic-assisted vaginal hysterectomy, which includes preparing the patient, creating a pneumoperitoneum, making incisions, utilizing laparoscopic instruments, and completing the vaginal portion of the procedure.
In simple words: The doctor removes the uterus, cervix, and fallopian tubes (possibly the ovaries too) through the vagina. A thin, lighted tube (laparoscope) is used to cut the upper attachments of the uterus. This is often done for fibroids or a large uterus.
This procedure involves removing the uterus, cervix, and fallopian tubes (with or without ovaries) through the vagina.The surgeon uses a laparoscope to sever the upper uterine and ovarian attachments.This approach is often used to treat fibroids or manage a uterus larger than 250 grams.
Example 1: A 45-year-old female patient presents with heavy menstrual bleeding and a significantly enlarged uterus due to multiple fibroids. A laparoscopic-assisted vaginal hysterectomy (LAVH) with bilateral salpingectomy is performed., A 50-year-old female patient experiences chronic pelvic pain attributed to uterine fibroids.A LAVH with bilateral salpingo-oophorectomy is performed to alleviate the pain and address the fibroids., A 38-year-old female patient with a history of endometriosis and a large uterus undergoes a LAVH with bilateral salpingectomy to reduce the risk of future complications.
Complete surgical history, physical exam findings, imaging studies (ultrasound, MRI) confirming uterine size and fibroids, operative report detailing procedure steps and specimen description, pathology report confirming the nature and extent of the pathology removed.
** This procedure is considered a major surgical procedure and requires a high level of surgical expertise.Adequate post-operative care is essential for patient recovery.
- Revenue Code: P1E (MAJOR PROCEDURE - HYSTERECTOMY)
- Payment Status: Active
- Modifier TC rule: TC modifier (Technical Component) is not applicable to this code as it represents the entire professional and technical service.
- Specialties:Obstetrics and Gynecology
- Place of Service:Ambulatory Surgical Center, Inpatient Hospital, Hospital Outpatient Department