CPT Code 58548 Laparoscopic Radical Hysterectomy with Pelvic & Para‑aortic Lymphadenectomy

Laparoscopic radical hysterectomy with pelvic and para‑aortic lymphadenectomy is a technically demanding procedure often performed for gynecologic malignancies. The combination of radical uterine removal, lymph node dissection, and optional adnexal removal increases surgical complexity, documentation requirements, and coding considerations. Accurate operative notes, specifying the laparoscopic approach, extent of lymphadenectomy, and any adnexal removal, are essential. Leveraging specialized OBGYN medical billing services ensures proper coding, compliance, and optimal reimbursement while allowing surgeons to focus on patient care.

CPT Code 58548 – Description

The official definition of CPT code 58548 is:

“Laparoscopic radical hysterectomy with bilateral pelvic lymphadenectomy and para‑aortic lymph node sampling or biopsy; includes removal of tube(s) and/or ovary(s) if clinically indicated.”

This code describes a complex minimally invasive laparoscopic procedure performed primarily for gynecologic malignancies. The procedure involves radical removal of the uterus and surrounding parametrial tissue, bilateral pelvic lymph node dissection, and para‑aortic lymph node sampling or biopsy. Removal of adnexal structures (tube(s) and/or ovary(s)) is included if clinically indicated.

The scope of CPT 58548 includes laparoscopic entry, port placement, radical hysterectomy, extensive lymph node dissection, optional adnexal removal, hemostasis, and laparoscopic closure. This code is distinct from standard laparoscopic or supracervical hysterectomies due to its oncologic complexity and extent of nodal dissection.

Scenarios Where CPT Code 58548 Is Applicable

You would bill CPT code 58548 in the following situations:

Gynecologic Malignancy Requiring Radical Surgery:

When a patient has early-stage cervical or uterine malignancy and requires radical hysterectomy with pelvic and para‑aortic lymph node evaluation.

Example:

A patient with stage IB cervical cancer undergoes laparoscopic radical hysterectomy with bilateral pelvic lymphadenectomy and para‑aortic lymph node biopsy. One ovary is removed due to clinical indication, and the procedure is completed minimally invasively.

Minimally Invasive Surgical Approach:

When the radical hysterectomy and lymph node dissections are performed entirely via laparoscopy without conversion to an open approach.

Extent of Lymph Node Dissection:

Bilateral pelvic and para‑aortic lymph node sampling or biopsy must be documented in the operative note.

Applicable Modifiers for CPT Code 58548

The following modifiers may be used with CPT code 58548 when appropriate:

Modifier 22 – Increased Procedural Services

Used when the procedure requires significantly increased time, effort, or technical complexity due to factors such as extensive nodal dissection, adhesions, or distorted pelvic anatomy.

Modifier 51 – Multiple Procedures

Applicable if CPT 58548 is performed with another significant, separately reportable procedure during the same operative session.

Modifier 59 – Distinct Procedural Service

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

Modifier 62 – Two Surgeons

Reported when two surgeons share responsibility for main portions of the procedure due to its 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 58548 – Billing & Reimbursement

To ensure proper reimbursement for CPT code 58548, follow these key steps:

Justify Medical Necessity:

Document the patient’s diagnosis (e.g., cervical cancer, uterine malignancy, pre‑cancerous lesions) and clinical indications for radical hysterectomy with lymph node dissection.

Use Accurate ICD-10 Codes:

Pair CPT 58548 with diagnosis codes that reflect the malignancy and the clinical rationale for radical surgery.

Confirm Surgical Details:

The operative report should clearly document:

• Laparoscopic approach
• Radical hysterectomy and parametrial removal
• Bilateral pelvic and para‑aortic lymph node sampling/biopsy
• Removal of tube(s) and/or ovary(s), if indicated
• Intraoperative complications or technical challenges

Detailed Documentation:

Ensure the operative note includes all surgical steps, lymph node dissection extent, hemostasis, closure, and any complications.

Reimbursement Considerations:

Reimbursement is typically higher due to procedural complexity and oncologic significance. Accurate documentation is critical to differentiate CPT 58548 from simpler laparoscopic hysterectomy codes and to ensure payer compliance and proper reimbursement.

BillingFreedom: Expert Support for Laparoscopic Radical Hysterectomy with Lymphadenectomy

Laparoscopic radical hysterectomy with bilateral pelvic lymphadenectomy and para‑aortic node sampling is a highly complex procedure requiring precise coding, detailed operative documentation, and careful modifier application. Accurate reporting is essential to ensure reimbursement and compliance with payer requirements.

BillingFreedom provides specialized OBGYN medical billing services in Kentucky to efficiently manage even the most complex laparoscopic procedures. Our expert team ensures claims are fully documented, correctly coded, and compliant with all payer guidelines. From operative reporting to modifier selection and preauthorization support, we streamline the billing process so physicians can focus on patient care. 

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