CPT Code 58152 Complete Billing & Coding Guide for Hysterectomy Procedures

Accurate CPT coding is essential for OBGYN practices to ensure compliance, correct reimbursement, and protection from payer audits. CPT 58152 describes a total abdominal hysterectomy (TAH) with removal of the uterus, cervix, fallopian tubes, and ovaries. It represents one of the most comprehensive open abdominal hysterectomy procedures, performed for complex gynecologic conditions requiring the complete removal of the uterus and adnexa.

This guide provides detailed insights into the use of CPT 58152, including indications, documentation, modifiers, reimbursement details, and examples, enabling providers to bill and code this major gynecologic procedure confidently.

CPT Code 58152 – Description

Official Definition: “Total abdominal hysterectomy (corpus and cervix), with removal of tube(s) and/or ovary(s).”

This code is used when the surgeon removes both the uterus and cervix, along with one or both ovaries and/or fallopian tubes, through an open abdominal incision. It involves more extensive dissection than CPT 58150, as adnexal removal adds complexity and operative time.

Description of the Procedure

During a total abdominal hysterectomy with salpingo-oophorectomy, the patient is placed under general anesthesia. The surgeon makes a horizontal or vertical incision in the lower abdomen, opens the peritoneum, and mobilizes the uterus and adnexa (tubes and ovaries). The uterine vessels, ovarian ligaments, and fallopian tubes are carefully ligated and divided. The uterus, cervix, and adnexa are then removed en bloc or separately. Finally, the vaginal cuff is closed, and the abdomen is sutured in layers.

Surgical Purpose and Scope

This extensive operation is performed for conditions affecting the uterus and ovaries simultaneously, such as large fibroids, severe endometriosis, ovarian cysts, or suspected malignancy. The goal is to remove all affected reproductive structures to relieve symptoms, prevent recurrence, and eliminate disease.

When to Use CPT 58152

CPT 58152 is reported when a total abdominal hysterectomy with removal of tubes and/or ovaries is performed. It is medically necessary for patients presenting with:

• Advanced uterine fibroids with adnexal involvement
• Endometriosis or adenomyosis affecting the uterus and ovaries
• Complex ovarian cysts, benign or premalignant masses
• Postmenopausal bleeding with adnexal pathology
• Early-stage gynecologic malignancies requiring complete resection
• Chronic pelvic pain unresponsive to conservative management

When Not to Use CPT 58152

Do not report 58152 when:

• Only the uterus and cervix are removed (use 58150).
• The surgery is performed vaginally (use 58262–58294).
• The procedure is laparoscopic (use 58571 or 58573).
• A radical hysterectomy is performed (use 58180).
• Always review the operative report to confirm removal of the uterus, cervix, and adnexa through an open abdominal approach.

Coding Guidelines

Report CPT 58152 once per surgical session. The code includes the excision of the uterus, cervix, and adnexa (tubes and/or ovaries). Do not report additional codes for salpingo-oophorectomy when performed at the same session — it is included in 58152.

Suppose an additional distinct pelvic or abdominal procedure is performed, such as a lymph node dissection or extensive adhesiolysis beyond routine. In that case, those services may be separately reportable with appropriate modifiers and supporting documentation.

Global Period and Postoperative Care

This code carries a 90-day global period, encompassing all routine postoperative visits, wound checks, and standard follow-up care. Complications that require return to the operating room can be separately reported if documented properly.

Site of Service and Authorization

CPT 58152 is generally performed in a hospital inpatient or outpatient surgical center setting, given its complexity. Most payers require prior authorization for hysterectomy procedures, especially when adnexal removal is involved. Ensure preoperative imaging, diagnosis codes, and medical necessity are well-documented.

Average Reimbursement and Payer Trends

Due to its complexity, CPT 58152 is reimbursed at a higher rate than CPT 58150. On average, Medicare reimbursement for the professional component ranges from $1,300 to $1,500, depending on region and payer contract.

For hospital or ASC facility fees, the payment may vary significantly based on the site of service, typically ranging from $5,500 to $7,000. Patients’ out-of-pocket costs depend on coverage specifics, but average cost-sharing may fall between $550 and $700.

Bundling and Reduction Rules

CPT 58152 is subject to multiple procedure reduction rules when performed with other major surgeries. Routine lysis of adhesions, oophorectomy, and salpingectomy are bundled, but additional unrelated procedures (e.g., appendectomy or lymph node sampling) can be reported separately if justified by documentation.

Proper Modifier Application for CPT 58152

Accurate modifier usage ensures proper claim adjudication and helps prevent underpayment or denials.

• Modifier 51 – When multiple procedures are performed during the same session.
• Modifier 54 – When the physician provides only the surgical service.
• Modifier 55 – When another provider handles postoperative management.
• Modifier 59 – When another distinct, unrelated procedure is performed during the same operative session.
• Modifier 22 – For increased procedural services (e.g., extensive adhesions or unusually large uterus).
• Ensure the operative report justifies the use of modifiers through clear, detailed documentation.

Documentation Requirements

Essential Operative Note Elements

Comprehensive operative documentation supports accurate coding and protects against payer audits. The following details should always be included:

• Preoperative and postoperative diagnosis
• Indication for surgery (fibroids, endometriosis, cysts, malignancy)
• Type of incision and surgical approach
• Organs removed (uterus, cervix, tubes, ovaries)
• Intraoperative findings and complications
• Closure technique and postoperative condition
• Confirmation that the surgical specimen was sent for pathology

Importance of Complete Documentation

Detailed documentation establishes medical necessity, supports code selection, and validates modifier usage. Any additional complexity, such as extensive adhesiolysis or anatomical distortion, should be clearly described to support higher complexity coding or modifier 22 if applicable.

Example Scenarios For CPT Code 58152

Scenario 1 – Fibroid Uterus with Ovarian Cysts

A patient with large fibroids and bilateral ovarian cysts undergoes a total abdominal hysterectomy with bilateral salpingo-oophorectomy. Since both the uterus and adnexa were removed, report CPT 58152.

Scenario 2 – Endometriosis with Extensive Adhesions

A 42-year-old with chronic pelvic pain and dense pelvic adhesions from endometriosis undergoes a total abdominal hysterectomy with bilateral oophorectomy. If the adhesions make the procedure unusually difficult, use CPT 58152 with modifier 22 to indicate increased complexity.

Scenario 3 – Combined Abdominal Procedure

A patient undergoes a total abdominal hysterectomy with bilateral salpingo-oophorectomy and a concurrent omentectomy for benign cystic disease. Report CPT 58152 for the hysterectomy and CPT 49255 for the omentectomy with modifier 51.

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