CPT Code 58146 Endometrial sampling, D&C and Uterus Tumor Excision Procedures

Accurate CPT coding is essential for OBGYN practices to ensure proper reimbursement, maintain compliance, and prevent claim denials. CPT 58146 is used to report a complex abdominal myomectomy, a major open surgical procedure performed to remove multiple or large uterine fibroids from a significantly enlarged uterus. This comprehensive guide explains the code definition, indications, modifiers, billing rules, documentation needs, and reimbursement details, so providers can confidently bill and code for this advanced gynecologic procedure.

CPT Code 58146 – Description

Official Definition: "Myomectomy, excision of fibroid tumor(s) of uterus, abdominal approach; total weight of myomas greater than 250 grams."

This code represents a therapeutic open abdominal myomectomy, where the surgeon removes multiple fibroid tumors from the uterus through an abdominal incision. It is specifically used when the uterus, after removal of the fibroids, weighs more than 250 grams, or when the surgery involves the excision of five or more fibroids. Unlike laparoscopic or hysteroscopic approaches, this is a full open procedure requiring an incision through the abdominal wall to reach the uterus.

Step-by-Step Description of the Procedure

In this procedure, the surgeon creates a lower abdominal incision, usually a Pfannenstiel or midline incision, then makes one or more incisions into the uterine wall to access and remove the fibroids. After the fibroids are excised, the surgeon meticulously repairs the uterine muscle layers to restore structural integrity and reduce the risk of future uterine rupture, especially in women who wish to maintain fertility. The abdomen is then closed in layers.

Related CPT Code Clarifications

This surgery is more extensive than CPT 58145, which covers myomectomy for smaller fibroids or uterine weights under 250 grams. It should not be confused with laparoscopic myomectomy codes such as 58545 or 58546.

When to Use CPT 58146

CPT 58146 should be reported when a provider performs an open abdominal myomectomy that involves removing multiple fibroids from a uterus weighing more than 250 grams after fibroid removal. The procedure is medically necessary in cases where fibroids cause significant symptoms or functional problems.

Typical Clinical Scenarios

Typical indications include heavy menstrual bleeding, pelvic pressure, infertility due to uterine distortion, recurrent miscarriage linked to fibroid presence, and large or rapidly growing fibroids causing pain or compressive symptoms on nearby organs such as the bladder or bowel.

When Not to Report CPT 58146

Do not report CPT 58146 when the fibroids are removed laparoscopically or hysteroscopically, when the uterus weighs less than 250 grams (use CPT 58145 instead), or when a hysterectomy is performed instead of myomectomy. Additionally, diagnostic or minor uterine procedures performed separately should not be billed alongside this code unless they are clearly distinct and unrelated.

Coding Guidelines - CPT Code 58146

CPT 58146 is reported once per surgical session for the abdominal myomectomy procedure, regardless of the number of fibroids removed. According to standard coding rules, all related intraoperative services, such as hemostasis, wound closure, and simple adhesiolysis, are included in the code and should not be billed separately.

Global Surgical Package

The procedure carries a 90-day global period, meaning all routine postoperative care and visits are bundled into the reimbursement. This includes hospital follow-up and uncomplicated postoperative evaluations. Since myomectomy is a complex procedure often performed in a hospital inpatient or ambulatory surgical center setting, site-of-service rules apply. Providers should ensure accurate place-of-service coding to prevent payment delays.

Prior Authorization and Payer Requirements

Because of the surgical complexity and potential hospital admission, many payers require prior authorization for CPT 58146. It's important to include operative indications, fibroid size and number, and uterine weight in preauthorization submissions.

CPT Code 58146 - Reimbursement Information

CPT 58146 has a higher work RVU and reimbursement rate than CPT 58145 because of its increased complexity. According to the current Medicare Physician Fee Schedule and ASC payment indicators, this procedure typically reimburses between $1,100 and $1,300 for physician services, depending on geographic location and payer contracts. The average out-of-pocket cost for a Medicare beneficiary in an ASC or hospital outpatient setting is approximately $500–$600, although rates vary regionally.

Multiple Procedure Reductions and Payer Variability

The global surgical period is 90 days, and multiple procedure reduction rules apply when 58146 is billed along with other major surgeries during the same session. Commercial payer reimbursement depends on the specific contract terms, and providers should always check payer-specific fee schedules and coverage policies.

Modifiers - CPT Code 58146

Appropriate use of modifiers ensures accurate claim processing and payment.

• Modifier 51 is used when multiple procedures are performed during the same surgical session.
• Modifier 54 indicates surgical care only, while modifier 55 represents postoperative management only if these are shared between providers.
• Modifier 59 may be applied when a separate, distinct procedure is performed in the same session.
• Modifier 22 can be considered for unusually extensive or prolonged procedures with detailed supporting documentation.
• Modifiers LT and RT may be used if the payer requires laterality clarification, though this is uncommon for uterine procedures.

Key Elements of Operative Documentation

Accurate and detailed documentation is essential for compliance, correct coding, and defense against audits or denials. Operative notes should clearly reflect medical necessity, the extent of the surgery, and the complexity of the procedure.

Documentation Checklist for CPT 58146

Key documentation elements include the preoperative diagnosis (such as symptomatic fibroids or abnormal uterine bleeding), a description of the surgical approach, incision type, number and size of fibroids removed, total uterine weight after removal (confirming it exceeds 250 grams), repair technique, hemostasis method, intraoperative findings, and confirmation that the tissue was sent to pathology. Postoperative instructions and follow-up details should also be included to complete the record.

Importance of Thorough Recordkeeping

Comprehensive and compliant documentation not only ensures accurate reimbursement but also provides clinical justification for the extent of the surgical work performed.

Example Scenarios

Scenario 1 – Large Fibroid Uterus

A 39-year-old patient presents with severe pelvic pain and heavy menstrual bleeding. The uterus is enlarged to 16 weeks' size, and imaging shows multiple fibroids. The surgeon performs an open abdominal myomectomy, removing eight fibroids with a total uterine weight of 320 grams. The appropriate code is CPT 58146.

Scenario 2 – Fertility Preservation Surgery

A patient with infertility undergoes an open myomectomy for multiple fibroids, totaling 400 grams in weight. The uterus is reconstructed to preserve fertility. This case also warrants reporting CPT 58146.

Scenario 3 – Combined Procedure

A patient undergoes abdominal myomectomy along with ovarian cystectomy during the same session. In this case, CPT 58146 is reported for the myomectomy, and the appropriate cystectomy code (58740) is added with modifier 51 or 59, as applicable.

Why Choose BillingFreedom for OBGYN Billing

Abdominal myomectomy procedures are complex both surgically and from a billing standpoint. Proper coding, modifier use, and documentation are critical to ensure compliance and prevent claim rejections. BillingFreedom provides expert OBGYN medical billing services, designed to help practices manage the intricate details of surgical billing, coding, and claim submission.

Benefits of Partnering with BillingFreedom

Our certified coders are well-versed in the latest CMS and AAPC coding guidelines and understand the nuances of gynecological procedures like myomectomy. With BillingFreedom, your practice can reduce denials, accelerate reimbursement cycles, and maintain audit-ready compliance. We ensure clean claims, accurate code selection, and thorough documentation support, so you can focus on patient care while we handle the complexities of revenue cycle management.

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