CPT Code 58540 Hysteroplasty for Uterine Anomaly: Comprehensive Coding and Billing Guideline

OBGYN billing can be particularly complex due to the technical nature of reconstructive uterine surgeries. CPT code 58540 is used for a specialized gynecologic procedure involving the surgical correction of congenital uterine anomalies through an open abdominal approach. 

Because these cases are uncommon and highly detailed, precise coding and thorough documentation are essential. Errors in reporting this code can result in claim denials, delayed payments, or reimbursement reductions.

Here, we’ll explain the code’s description, scenarios where it is applicable, relevant modifiers, and critical billing and reimbursement guidelines to help ensure accurate claims submission and timely reimbursement.

CPT Code 58540 – Description

The official definition of CPT code 58540 is:

“Hysteroplasty, repair of uterine anomaly (Strassman type), abdominal approach.”

This code is used for a surgical reconstructive procedure in which a physician corrects a congenital uterine anomaly by reshaping and unifying the uterine cavity. The procedure is performed through an open abdominal incision and is intended to preserve the uterus while correcting its structural defect.

The surgery typically involves identifying the congenital anomaly, incising the uterus, reconstructing the uterine cavity into a single unified space, and performing layered closure of the uterine wall. CPT 58540 is distinct from hysterectomy or myomectomy codes, as it does not involve uterine removal or fibroid excision. Its purpose is strictly reconstructive rather than ablative or therapeutic.

Scenarios Where CPT Code 58540 Is Applicable

You would bill CPT code 58540 in the following situations:

Congenital Uterine Anomalies

When a patient has a congenital structural defect of the uterus that requires surgical reconstruction, such as a bicornuate uterus or a unicornuate uterus with a rudimentary horn.

Example:

A patient with a diagnosed bicornuate uterus experiences recurrent pregnancy loss. An abdominal Strassman-type hysteroplasty is performed to merge the uterine cavities into a single functional cavity.

Fertility-Related Indications

When a congenital uterine anomaly is contributing to infertility or recurrent miscarriage, and surgical correction is clinically indicated.

Symptomatic Structural Abnormalities

When uterine anomalies cause chronic pelvic pain, severe dysmenorrhea, or menstrual abnormalities that require surgical correction.

In all cases, the procedure must be performed via an abdominal (open) approach, and documentation must clearly describe the anomaly and the reconstructive steps taken.

Applicable Modifiers for CPT Code 58540

The following modifiers may be used with CPT code 58540 when appropriate:

Modifier 22 – Increased Procedural Services

This modifier is used when the procedure requires significantly more time, effort, or technical complexity than usual due to factors such as extensive adhesions, distorted anatomy, or prolonged reconstruction.

Modifier 51 – Multiple Procedures

Used when CPT 58540 is performed during the same operative session as another significant procedure.

Modifier 59 – Distinct Procedural Service

Applicable when a separate, distinct procedure is performed that is not normally bundled with hysteroplasty.

Modifier 62 – Two Surgeons

Used when two surgeons share responsibility for the main portions of the procedure due to its complexity.

Assistant Surgeon Modifiers (80, 81, 82)

Reported when an assistant surgeon is medically necessary for the procedure.

All modifier usage must be clearly supported by operative documentation.

CPT Code 58540 – Billing & Reimbursement

To ensure proper reimbursement for CPT code 58540, follow these key guidelines:

Justify Medical Necessity

Document the clinical indication for surgery, such as infertility, recurrent pregnancy loss, pelvic pain, or menstrual dysfunction, supported by imaging findings confirming the congenital uterine anomaly.

Use Accurate ICD-10 Codes

CPT 58540 must be paired with diagnosis codes that reflect congenital uterine anomalies and associated symptoms. The diagnosis should clearly support the need for reconstructive surgery.

Confirm Surgical Approach

Documentation must specify that the procedure was performed via an open abdominal approach, as laparoscopic or hysteroscopic repairs are coded differently.

Detailed Operative Documentation

The operative report should include identification of the anomaly, surgical reconstruction steps, uterine preservation, layered closure, and any complicating factors.

Reimbursement Considerations

Reimbursement varies based on payer policy, place of service, and geographic location. Due to the complexity and rarity of this procedure, many payers require pre-authorization and may conduct detailed claim reviews.

BillingFreedom: Expert Support for Complex Uterine Reconstruction Billing

Complex uterine reconstruction procedures, such as abdominal hysteroplasty for congenital anomalies, require meticulous documentation, precise coding, and careful modifier application. Even small gaps in the operative report, like missing details on the type of uterine anomaly, reconstruction steps, or complicating factors, can result in claim denials or reduced reimbursement. For busy physicians, managing these administrative requirements while providing optimal patient care can be challenging.

BillingFreedom provides specialized OBGYN medical billing services in Montana that handle even the most intricate scenarios. Our expert team ensures every claim is accurately coded, properly documented, and submitted according to payer guidelines. From preauthorization to modifier selection and post-operative reporting, we streamline the entire billing process, helping practices maximize reimbursement, maintain compliance, and focus on patient outcomes rather than administrative hurdles.

For more details about our exceptional OB/GYN billing services in Montana, please don't hesitate to contact us via email at info@billingfreedom.com or call us at +1 (855) 415-3472. 

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