CPT Code 58541 Laparoscopy, Supracervical Hysterectomy, Uterus 250 g or Less

OBGYN billing can be particularly complex due to the wide range of surgical approaches used in gynecologic procedures. CPT code 58541 is used to report a minimally invasive hysterectomy in which the uterine body is removed laparoscopically while the cervix is preserved. 

Because hysterectomy coding varies based on surgical approach, extent of removal, and uterine weight, precise coding and documentation are critical. Errors in reporting CPT 58541 can result in claim denials, downcoding, or delayed reimbursement.

CPT Code 58541 – Description

The official definition of CPT code 58541 is:

“Laparoscopic supracervical hysterectomy, uterus 250 g or less.”

This code is used for a minimally invasive surgical procedure in which a physician removes the uterine body only, while preserving the cervix, using a laparoscopic approach. The procedure is typically performed for benign gynecologic conditions when removal of the cervix is not clinically indicated.

The scope of CPT 58541 includes placement of laparoscopic ports, abdominal entry, dissection and removal of the uterine body, preservation of the cervix, achievement of hemostasis, and closure of laparoscopic port sites. This code is distinct from total laparoscopic hysterectomy and open hysterectomy codes, as it involves partial uterine removal with cervical preservation.

Scenarios Where CPT Code 58541 Is Applicable

You would bill CPT code 58541 in the following situations:

Benign Uterine Conditions:

When a patient has benign gynecologic conditions such as uterine fibroids, adenomyosis, or abnormal uterine bleeding that require hysterectomy but do not necessitate cervical removal.

Example:

A patient with symptomatic fibroids and a uterus weighing less than 250 grams undergoes a laparoscopic supracervical hysterectomy to relieve symptoms while preserving the cervix.

Minimally Invasive Surgical Approach:

When the procedure is performed entirely through a laparoscopic approach without conversion to an open abdominal surgery.

Uterine Weight Criteria:

When the uterus weighs 250 grams or less, as confirmed intraoperatively or by pathology.

Applicable Modifiers for CPT Code 58541

The following modifiers may be used with CPT code 58541 when appropriate:

Modifier 22 – Increased Procedural Services

Used when the laparoscopic procedure requires significantly increased time or effort due to factors such as dense adhesions, distorted anatomy, or unexpected complexity.

Modifier 51 – Multiple Procedures

Applicable when CPT 58541 is performed during the same operative session as another significant procedure.

Modifier 59 – Distinct Procedural Service

Used when a separate, distinct procedure is performed that is not typically bundled with the hysterectomy.

Modifier 62 – Two Surgeons

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

Assistant Surgeon Modifiers (80, 81, 82)

Used when an assistant surgeon is medically necessary.

All modifiers must be clearly supported by operative documentation.

CPT Code 58541 – Billing & Reimbursement

To ensure proper reimbursement for CPT code 58541, follow these key steps:

Justify Medical Necessity:

Document the patient’s symptoms and diagnosis, such as abnormal uterine bleeding, fibroids, or adenomyosis, that support the need for hysterectomy.

Use Accurate ICD-10 Codes:

CPT 58541 must be paired with diagnosis codes that reflect benign gynecologic conditions and justify a supracervical approach.

Confirm Surgical Details:

The operative report should clearly state:

• Laparoscopic approach
• Preservation of the cervix
• Uterine weight of 250 grams or less

Detailed Documentation:

Ensure the operative note includes surgical steps, uterine size, findings, hemostasis, and closure of laparoscopic port sites.

Reimbursement Considerations:

Reimbursement varies based on payer policy, place of service, and geographic location. Accurate documentation is essential to distinguish CPT 58541 from total laparoscopic hysterectomy or open hysterectomy codes and to avoid downcoding or denial.

BillingFreedom: Expert Support for Laparoscopic Supracervical Hysterectomy Billing

Accurate billing for laparoscopic supracervical hysterectomy procedures, such as CPT 58541, requires precise documentation, proper modifier use, and adherence to payer requirements. Even minor omissions, such as missing details on uterine weight, surgical approach, or operative complexity, can lead to claim denials or underpayments.

BillingFreedom offers expert OBGYN medical billing services in Minnesota to handle these challenges efficiently. Our team ensures that each claim is accurately coded, adequately documented, and submitted in accordance with payer guidelines. 

From preauthorization to operative reporting and modifier application, we streamline the billing process, helping physicians maximize reimbursement while focusing on patient care, even for technically demanding laparoscopic procedures like CPT 58541.

For more details about our exceptional OB/GYN billing services in Minnesota, 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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