CPT Code 58544 Laparoscopic Supracervical Hysterectomy with Adnexal Removal for Uterus >250 g

Laparoscopic supracervical hysterectomy with adnexal removal for a uterus larger than 250 grams presents unique clinical and administrative challenges. The combination of an enlarged uterus and removal of one or both adnexal structures increases procedural complexity, operative time, and documentation requirements. 

Accurate coding and detailed operative notes are essential to ensure proper reimbursement, support payer compliance, and reduce claim denials. Utilizing OBGYN medical billing services can help practices capture every critical detail while allowing physicians to focus on patient care.

CPT Code 58544 – Description

The official definition of CPT code 58544 is:

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

This code describes a laparoscopic 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. It is commonly performed for benign gynecologic conditions associated with uterine enlargement and adnexal disease, such as large fibroids, adenomyosis, endometriosis, or abnormal uterine bleeding.

The scope of CPT 58544 includes abdominal entry, laparoscopic port placement, dissection and removal of the enlarged uterine body, removal of the indicated adnexal structures, preservation of the cervix, achievement of hemostasis, and closure of laparoscopic port sites. This code is distinct from CPT 58541–58543, which either involve smaller uteri or do not include adnexal removal.

Scenarios Where CPT Code 58544 Is Applicable

You would bill CPT code 58544 in the following situations:

Benign Conditions With Enlarged Uterus and Adnexal Pathology:

When a patient has benign gynecologic conditions such as large fibroids, adenomyosis, endometriosis, or abnormal uterine bleeding and requires removal of one or both fallopian tubes and/or ovaries.

Example:

A patient with a uterus weighing more than 250 grams and bilateral ovarian pathology undergoes a laparoscopic supracervical hysterectomy with bilateral salpingo-oophorectomy, with preservation of the cervix.

Minimally Invasive Surgical Approach:

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

Uterine Weight and Adnexal Removal Criteria:

When the uterus weighs more than 250 grams, and removal of tube(s) and/or ovary(s) is documented.

Applicable Modifiers for CPT Code 58544

The following modifiers may be used with CPT code 58544 when appropriate:

Modifier 22 – Increased Procedural Services

Used when the procedure requires significantly increased time or effort due to severe adhesions, extensive endometriosis, prior surgeries, or unusually large uterine size.

Modifier 51 – Multiple Procedures

Applicable when CPT 58544 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 clearly supported by detailed operative documentation.

CPT Code 58544 – Billing & Reimbursement

To ensure proper reimbursement for CPT code 58544, follow these key steps:

Justify Medical Necessity:

Clearly document the patient’s symptoms and diagnoses, such as large fibroids, adenomyosis, endometriosis, or abnormal uterine bleeding, and explain the clinical rationale for adnexal removal.

Use Accurate ICD-10 Codes:

CPT 58544 must be paired with diagnosis codes that support both uterine enlargement and the removal of tube(s) and/or ovary(s).

Confirm Surgical Details:

The operative report should clearly document:

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

Detailed Documentation:

Ensure the operative note includes uterine size or weight, adnexa removed, intraoperative findings, hemostasis, and closure of laparoscopic port sites.

Reimbursement Considerations:

Reimbursement varies by payer, place of service, and geographic location. Accurate documentation is essential to differentiate CPT 58544 from uterus-only or smaller-uterus hysterectomy codes and to support payer compliance.

BillingFreedom: Expert Support for Laparoscopic Supracervical Hysterectomy with Adnexal Removal

Laparoscopic supracervical hysterectomy for uteri larger than 250 grams with removal of tubes and/or ovaries requires precise documentation, accurate coding, and careful modifier selection. The combination of uterine enlargement and adnexal removal increases procedural complexity, making thorough operative notes critical for reimbursement and claim approval.

BillingFreedom provides specialized OBGYN medical billing services in Maine to efficiently manage these complex procedures. Our expert team ensures every claim is accurately coded, fully documented, and compliant with payer guidelines. From preauthorization and operative reporting to modifier application, we streamline the billing process, allowing practices to maximize reimbursement while physicians focus on patient care. 

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