CPT Code 58150 Complete Billing & Coding Guide for Hysterectomy Procedures

Accurate CPT coding is essential for OBGYN providers to maintain compliance, ensure proper reimbursement, and minimize denials. CPT 58150 is used to report a total abdominal hysterectomy (TAH), a major gynecologic surgical procedure involving the removal of the uterus and cervix through an abdominal incision. This code is one of the most frequently used hysterectomy codes and requires precise documentation and billing practices to ensure accurate payment.

This comprehensive guide explains the correct use of CPT 58150, including its Definition, indications, coding guidelines, modifier usage, documentation standards, and reimbursement details, allowing OBGYN practices to code confidently and compliantly.

CPT Code 58150 – Description

Official Definition: “Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s).”

This code represents a complete removal of the uterus (corpus) and cervix via an open abdominal approach. It may also include the removal of fallopian tubes and/or ovaries, but this is optional and does not change the primary code used.

Description of the Procedure

In a total abdominal hysterectomy, the surgeon makes a horizontal (Pfannenstiel) or vertical incision in the lower abdomen to access the pelvic organs. The uterus and cervix are carefully separated from surrounding tissues, including the bladder, fallopian tubes, and supporting ligaments. Once detached, the uterus is removed through the abdominal incision, and the vaginal cuff is sutured closed. If the ovaries or fallopian tubes are also removed, this is included within the same procedure and does not require additional codes unless a more extensive pelvic procedure is performed.

Clinical Purpose of the Procedure

CPT 58150 is typically performed to treat various gynecologic conditions, such as uterine fibroids, abnormal uterine bleeding, endometriosis, uterine prolapse, adenomyosis, or gynecologic malignancies. It is considered a major inpatient or ambulatory surgery requiring careful postoperative management and is generally performed when conservative treatments have failed or when uterine preservation is not indicated.

When to Use CPT 58150

CPT 58150 is reported when a provider performs a total abdominal hysterectomy through an open surgical approach. Common indications include:

• Symptomatic uterine fibroids cause pain or heavy bleeding.
• Chronic pelvic pain due to endometriosis or adenomyosis
• Uterine prolapse requiring definitive surgical correction
• Gynecologic cancers involving the uterus or cervix
• Persistent abnormal uterine bleeding unresponsive to medical therapy

When Not to Use CPT 58150

Do not report CPT 58150 if a supracervical hysterectomy is performed (use 58180 instead), if the surgery is performed vaginally (use 58260–58294), or laparoscopically (use 58570–58573). If a radical hysterectomy is performed for malignancy, use the appropriate radical hysterectomy code (58180 or 58210 series). Always confirm that both the uterus and cervix are removed to justify the use of 58150.

Coding Guidelines

CPT 58150 should be reported once per surgical session for the removal of the uterus and cervix via an abdominal incision. The code includes all standard intraoperative services such as incision, exposure, organ mobilization, hemostasis, and closure. Lysis of adhesions, minor hemostasis, and simple cystectomy or oophorectomy are bundled into the code unless a distinct and separately reportable procedure is performed.

Global Surgical Package and Follow-up Care

This procedure has a 90-day global period, which includes routine postoperative visits, standard wound care, and uncomplicated follow-up management. Postoperative complications that require return to the operating room may be separately billable if appropriately documented.

Site of Service and Authorization

A total abdominal hysterectomy is typically performed in a hospital inpatient or outpatient surgical setting, rarely in an office-based environment. Many commercial and government payers require prior authorization due to the complexity and cost of the procedure. Ensure that operative indications, diagnosis codes, and preoperative imaging results are submitted to support medical necessity.

Reimbursement Information

CPT 58150 carries a higher work RVU and payment value compared to vaginal or laparoscopic hysterectomies because it involves a larger incision, longer operative time, and more extensive surgical exposure.

According to the latest Medicare Fee Schedule data, the average physician reimbursement for CPT 58150 ranges between $1,200 and $1,400, depending on geographic location and payer contract. The average patient cost share in an ASC or hospital outpatient setting is approximately $550 to $650, though regional and payer variations apply.

Global Period and Bundling Considerations

The global period is 90 days, during which all routine postoperative care is included in the initial payment. When multiple procedures are performed, standard multiple surgery reduction rules apply, and any distinct additional procedures must be properly documented and supported with appropriate modifiers.

Correct Use of Modifiers for CPT 58150

Using the correct modifiers helps clarify the scope of the provider’s work and ensures accurate reimbursement.

• Modifier 51 is used when multiple procedures are performed during the same surgical session.
• Modifier 54 should be appended if the surgeon performs only the operative portion of the service, while modifier 55 is applied when another physician provides postoperative management.
• Modifier 59 may be used to indicate a distinct procedural service if another unrelated operation is performed during the same session.
• Modifier 22 is applicable when the surgery is unusually complex or prolonged due to extensive adhesions, a large uterus, or previous surgical scarring, provided detailed supporting documentation is included.

Documentation Requirements

Thorough and detailed operative documentation is critical for accurate coding and audit protection. Documentation must clearly establish the medical necessity, the extent of surgery, and the specific structures removed.

Essential Documentation Details

Operative notes should include:

• Preoperative and postoperative diagnoses
• Indication for hysterectomy (e.g., fibroids, endometriosis, prolapse)
• Surgical approach (abdominal, incision type)
• Organs removed (uterus and cervix, with or without adnexa)
• Intraoperative findings (adhesions, pathology, uterine size)
• Repair and closure technique
• Any complications or additional procedures performed.
• Confirmation that the specimen was sent for pathology evaluation

Complete, precise documentation ensures coding accuracy and supports payer review in the event of an audit.

Example Scenarios

Scenario 1 – Fibroid Uterus

A 46-year-old patient with heavy menstrual bleeding and a 14-week–sized fibroid uterus undergoes an open abdominal hysterectomy. The surgeon removes the uterus and cervix but leaves both ovaries intact. The correct code is CPT 58150.

Scenario 2 – Endometriosis with Adnexal Removal

A patient with severe pelvic pain due to endometriosis undergoes a total abdominal hysterectomy with bilateral salpingo-oophorectomy. Since the code includes “with or without” removal of tubes and ovaries, CPT 58150 still applies.

Scenario 3 – Combined Abdominal Procedure

A surgeon performs a total abdominal hysterectomy and, at the same session, removes a large ovarian cyst. In this case, report CPT 58150 for the hysterectomy and CPT 58740 for the cystectomy, appending modifier 51 to indicate multiple procedures.

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