CPT Code 58546 Laparoscopic/Hysteroscopic Procedures on the Corpus Uteri

Accurate coding and documentation are key when billing for advanced gynecologic procedures. CPT 58546 is used to report a laparoscopic myomectomy - specifically, when five or more fibroids are removed from the uterus and/or the total weight of the fibroids exceeds 250 grams.

This is a complex, minimally invasive surgery that demands both surgical skill and precise coding to ensure full and timely reimbursement. Understanding payer rules, documentation standards, and proper modifier usage helps OBGYN practices avoid denials and improve revenue performance.

CPT Code 58546 – Description of the Procedure

Official CPT Definition: “Laparoscopy, surgical, myomectomy, 5 or more myomas and/or total weight greater than 250 g, with or without morcellation.”

This code applies when the surgeon removes multiple or large fibroids (myomas) via a laparoscopic approach. Using specialized instruments, the physician enters the abdominal cavity through small incisions, identifies the fibroids, excises them from the uterine wall, and closes the defects to preserve uterine integrity.

It represents a more extensive surgery than CPT 58545 (for 1–4 fibroids ≤250 g) and should only be used when the total fibroid burden exceeds that threshold.

When to Use CPT 58546

Report CPT 58546 when the procedure meets all the following criteria:

• The approach is laparoscopic (not open).
• Five or more fibroids are removed, or the total weight of excised fibroids exceeds 250 grams.
• The intent of the procedure is therapeutic - to treat symptoms such as pain, pressure, or infertility due to uterine fibroids.

Common indications include:

• Symptomatic uterine leiomyomas causing abnormal bleeding or pelvic pain.
• Infertility due to the distortion of the uterine cavity by fibroids.
• Bulk-related symptoms like urinary frequency or pressure.
• Rapidly enlarging fibroids where malignancy cannot be ruled out.

Do not report this code when:

• The surgeon performs a diagnostic laparoscopy only.
• The fibroids are removed via laparotomy - use CPT 58146 instead.
• The myomectomy is part of a total laparoscopic hysterectomy - report the appropriate hysterectomy code.

Coding Guidelines and Billing Instructions

Correct application of CPT 58546 ensures compliance and prevents underbilling.

• Report 58546 once per operative session, even if fibroids are removed from multiple uterine locations.
• Do not bill for laparoscopic diagnostic entry separately; it is included in this code.
• Morcellation (manual or power-assisted) is bundled into this procedure and not separately billable.
• Lysis of adhesions may be billed separately only if extensive and clearly documented as a distinct service - append modifier 59 if appropriate.
• This procedure carries a 90-day global period, which includes typical postoperative care.

Reimbursement and Coverage Considerations

Reimbursement for CPT 58546 varies based on the place of service and payer policy.

• Average Medicare payment (non-facility): Around $1,150–$1,400
• Facility (ASC/hospital): Reimbursement is adjusted due to facility fees.
• Global period: 90 days
• Multiple surgery reduction: Applies when performed with other major procedures.

Many commercial insurers follow CMS guidelines but may have specific prior authorization requirements for laparoscopic myomectomy. Always verify coverage and document medical necessity (symptoms, imaging, uterine size, fibroid count).

Modifier Use

Appropriate modifiers communicate the scope and responsibility of care:

• Modifier 22 – Increased procedural services (when extensive adhesiolysis or unusually long surgery time is required).
• Modifier 51 – Multiple procedures in the same session.
• Modifier 54 – Surgical care only.
• Modifier 55 – Postoperative management only.
• Modifier 59 – Distinct procedural service (if separate laparoscopic work performed).

Avoid modifier overuse - improper application can delay or reduce payment.

Documentation Requirements

Detailed operative notes support accurate billing and audit readiness. Include:

• Clinical indication (fibroid-related bleeding, infertility, bulk symptoms).
• Number, size, and weight of fibroids removed.
• Approach (laparoscopic, with or without morcellation).
• Technique for hemostasis and uterine wall repair.
• Estimated blood loss and any intraoperative complications.
• Postoperative plan and recovery details.

This level of specificity validates the use of CPT 58546 over simpler codes and provides defense during payer audits or reviews.

Example Scenarios

Scenario 1 – Large Multiple Fibroids Removed

A patient presents with menorrhagia and pelvic pressure. Laparoscopic myomectomy is performed, removing seven fibroids weighing 320 grams total. The uterus is reconstructed, and all incisions are closed laparoscopically.

→ Bill CPT 58546.

Scenario 2 – Infertility Related to Uterine Fibroids

A 34-year-old woman undergoing infertility workup is found to have multiple subserosal and intramural fibroids. The surgeon performs a laparoscopic myomectomy, excising six fibroids totaling 280 grams.

→ Report CPT 58546 (meets both number and weight criteria).

Scenario 3 – Extensive Laparoscopic Myomectomy with Adhesiolysis

During a laparoscopic myomectomy, the provider performs prolonged adhesiolysis unrelated to the fibroid dissection.

→ Report CPT 58546 and append modifier 59 for the adhesiolysis if documentation supports separate medical necessity.

Each example demonstrates how procedural complexity and documentation determine appropriate billing.

Why Choose BillingFreedom for OBGYN Billing

Surgical procedures like laparoscopic myomectomy require advanced coding accuracy and strict payer compliance to avoid denials. That’s why many practices trust BillingFreedom for their OBGYN medical billing services.

Our certified team understands the coding nuances for fibroid surgeries and other gynecologic procedures, ensuring that your claims are clean, compliant, and optimized for reimbursement.

With BillingFreedom’s OBGYN medical billing services, you gain:

• Expert claim review and submission.
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• Up-to-date compliance with CMS and AAPC coding rules.
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For more details about our exceptional OBGYN medical billing services, 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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