CPT Code 58545 Laparoscopic Myomectomy (1–4 Fibroids ≤ 250 g): Definition and Scope

When managing uterine fibroids that are limited in number and size, laparoscopic myomectomy using CPT 58545 offers a uterus‑preserving, minimally invasive solution. Yet, even small‑scale myomectomy requires accurate documentation of the number, type, and weight of fibroids, surgical approach, and operative details. For busy practices, partnering with specialized OBGYN medical billing services ensures that every technical detail is properly coded and billed, reducing denials and maximizing reimbursement, while surgeons remain focused on patient care.

CPT Code 58545 – Description

The official definition of CPT code 58545 is:

“Laparoscopic myomectomy, 1–4 fibroids, uterus 250 g or less.”

This code describes a minimally invasive procedure in which a physician removes up to four fibroids from the uterus while preserving the organ. The procedure is typically indicated for symptomatic fibroids causing heavy menstrual bleeding, pelvic pain, or reproductive issues.

The scope of CPT 58545 includes laparoscopic entry and port placement, identification and enucleation of 1–4 fibroids, hemostasis at the myomectomy sites, and closure of laparoscopic ports. This code is distinct from CPT 58546 and 58547, which are used for removal of more fibroids or larger uteri.

Scenarios Where CPT Code 58545 Is Applicable

You would bill CPT code 58545 in the following situations:

Symptomatic Fibroids (1–4) in a Smaller Uterus:

When a patient presents with 1–4 fibroids in a uterus weighing ≤250 grams that are causing heavy menstrual bleeding, pelvic pain, or fertility issues.

Example:

A patient with two intramural fibroids measuring 3 cm and 4 cm undergoes a laparoscopic myomectomy. The total uterine weight is under 250 grams, and the uterus is preserved.

Minimally Invasive Surgical Approach:

When the procedure is performed entirely laparoscopically without conversion to open surgery.

Fibroid and Uterine Size Criteria:

The code applies only when the number of fibroids is 1–4 and the total uterine weight is ≤250 grams.

Applicable Modifiers for CPT Code 58545

The following modifiers may be used with CPT code 58545 when appropriate:

Modifier 22 – Increased Procedural Services

Used when the procedure requires significantly more time or effort than usual due to complex fibroid location, dense adhesions, or unusual anatomy.

Modifier 51 – Multiple Procedures

Applicable when CPT 58545 is performed during the same operative session as another significant, separately reportable procedure.

Modifier 59 – Distinct Procedural Service

Used when a distinct procedure is performed that is not typically bundled with the laparoscopic myomectomy.

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 operative documentation.

CPT Code 58545 – Billing & Reimbursement

To ensure proper reimbursement for CPT code 58545, follow these key steps:

Justify Medical Necessity:

Document the patient’s symptoms and diagnosis, including heavy menstrual bleeding, pelvic pain, or infertility related to 1–4 fibroids.

Use Accurate ICD-10 Codes:

CPT 58545 must be paired with diagnosis codes that reflect benign uterine fibroids and their clinical impact.

Confirm Surgical Details:

The operative report should clearly document:

• Laparoscopic approach
• Number, size, and location of fibroids
• Total uterine weight ≤250 grams
• Preservation of the uterus

Detailed Documentation:

Ensure the operative note includes surgical steps, intraoperative findings, hemostasis, and closure of laparoscopic ports. Note any complications or technical challenges.

Reimbursement Considerations:

Reimbursement depends on payer policy, place of service, and geographic location. Clear documentation is critical to differentiate CPT 58545 from larger-scale myomectomies (CPT 58546 or 58547) and to support accurate billing.

BillingFreedom: Expert Support for Laparoscopic Myomectomy (1–4 Fibroids ≤250 g)

Even small-scale laparoscopic myomectomy for 1–4 fibroids ≤250 g requires meticulous documentation, accurate coding, and careful modifier application. Though technically less complex than larger myomectomies, proper reporting is essential to ensure reimbursement and minimize claim denials.

BillingFreedom provides specialized OBGYN medical billing services in Louisiana to manage these procedures efficiently. Our team ensures claims are fully documented, accurately coded, and compliant with payer requirements. From operative reporting to modifier selection and preauthorization support, we streamline billing so physicians can focus on patient care. 

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

Your financial tranquility is our priority!