CPT Code 58542 Laparoscopic Supracervical Hysterectomy with Removal of Tubes and/or Ovaries

Performing a laparoscopic supracervical hysterectomy with adnexal removal requires careful attention to both surgical detail and documentation. Even when dealing with smaller uteri, the addition of tubes and/or ovaries adds complexity that can affect coding, reimbursement, and compliance. Leveraging OBGYN medical billing services helps practices accurately capture these nuances, ensuring claims reflect the full scope of the procedure while reducing the risk of denials and allowing physicians to concentrate on patient care.

CPT Code 58542 – Description

The official definition of CPT code 58542 is:

“Laparoscopic supracervical hysterectomy, uterus 250 g or less; with removal of tube(s) and/or ovary(s).”

This code is used for a minimally invasive surgical procedure in which the physician removes the uterine body while preserving the cervix and also removes one or both fallopian tubes and/or ovaries using a laparoscopic approach. The procedure is typically performed for benign gynecologic conditions when adnexal pathology is present or prophylactic removal is clinically indicated.

The scope of CPT 58542 includes placement of laparoscopic ports, abdominal entry, dissection and removal of the uterine body, removal of the indicated adnexa, preservation of the cervix, achievement of hemostasis, and closure of laparoscopic port sites. This code is distinct from CPT 58541, which does not include removal of tubes or ovaries.

Scenarios Where CPT Code 58542 Is Applicable

You would bill CPT code 58542 in the following situations:

Benign Gynecologic Conditions With Adnexal Pathology:

When a patient has benign conditions such as fibroids, adenomyosis, endometriosis, or abnormal uterine bleeding and requires removal of one or both fallopian tubes and/or ovaries in addition to supracervical hysterectomy.

Example:

A patient with symptomatic fibroids and endometriosis undergoes a laparoscopic supracervical hysterectomy with bilateral salpingo-oophorectomy. The uterus weighs less than 250 grams, and the cervix is preserved.

Minimally Invasive Surgical Approach:

When the procedure is performed entirely via laparoscopy without conversion to an open approach.

Uterine Weight Criteria:

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

Applicable Modifiers for CPT Code 58542

The following modifiers may be used with CPT code 58542 when appropriate:

Modifier 22 – Increased Procedural Services

Used when the procedure requires significantly increased time or effort due to factors such as dense adhesions, severe endometriosis, or distorted pelvic anatomy.

Modifier 51 – Multiple Procedures

Applicable when CPT 58542 is performed during the same operative session as another significant, separately reportable procedure.

Modifier 59 – Distinct Procedural Service

Used when a distinct, non-bundled procedure is performed during the same surgical encounter.

Modifier 62 – Two Surgeons

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

Assistant Surgeon Modifiers (80, 81, 82)

Used when an assistant surgeon is medically necessary.

All modifier usage must be supported by clear and detailed operative documentation.

CPT Code 58542 – Billing & Reimbursement

To ensure proper reimbursement for CPT code 58542, follow these key steps:

Justify Medical Necessity:

Document the patient’s symptoms and diagnoses, such as fibroids, adenomyosis, endometriosis, or abnormal uterine bleeding, and clearly explain the need for adnexal removal.

Use Accurate ICD-10 Codes:

CPT 58542 must be paired with diagnosis codes that support both the hysterectomy and the removal of one or both fallopian tubes and/or ovaries.

Confirm Surgical Details:

The operative report should clearly document:

• Laparoscopic approach
• Preservation of the cervix
• Removal of one or both tubes and/or ovaries
• Uterine weight of 250 grams or less

Detailed Documentation:

Ensure the operative note includes all surgical steps, intraoperative 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 58542 from CPT 58541 and other hysterectomy codes and to avoid downcoding or claim denials.

BillingFreedom: Expert Support for Laparoscopic Supracervical Hysterectomy with Adnexal Removal

Performing a laparoscopic supracervical hysterectomy with removal of tubes and/or ovaries requires meticulous documentation, precise coding, and careful modifier application. Even for uteri ≤250 grams, the addition of adnexal removal increases complexity, which can affect reimbursement and claim approval.

BillingFreedom provides specialized OBGYN medical billing services in Alabama to handle these intricate procedures. Our team ensures each claim is accurately coded, thoroughly documented, and compliant with payer guidelines. 

From preauthorization to operative reporting and modifier selection, we streamline the billing process, helping practices maximize reimbursement while physicians focus on patient care.

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