CPT Code 58550 Laparoscopy with Vaginal Hysterectomy (Uterus ≤ 250 g)

Laparoscopically-assisted vaginal procedures often require a coordinated approach, both surgically and administratively, to ensure clean documentation and accurate claim handling. When managing cases that involve combined laparoscopic and vaginal techniques, attention to operative detail becomes essential for smooth reimbursement. 

Partnering with specialized OBGYN medical billing services helps physicians avoid coding pitfalls, maintain compliance, and streamline the financial side of care, especially in procedures where technique and documentation precision directly impact coding accuracy.

CPT Code 58550 – Description

The official definition of CPT code 58550 is:

“Laparoscopically assisted vaginal hysterectomy, uterus 250 g or less.”

This code describes a minimally invasive procedure in which the surgeon performs initial dissection laparoscopically, including mobilization of the uterus, ligaments, and vascular pedicles, followed by removal of the uterus and cervix through the vaginal route. Both the laparoscopic and vaginal components must be documented in the operative note to justify the use of this code.

The scope of CPT 58550 includes laparoscopic entry and port placement, detachment of uterine ligaments and vascular pedicles via laparoscopy, vaginal removal of the uterus and cervix, achievement of hemostasis, and closure as appropriate.

Scenarios Where CPT Code 58550 Is Applicable

You would bill CPT code 58550 in the following situations:

Small Uterus Requiring Combined Approach:

When a patient has a uterus ≤250 grams and requires removal via a laparoscopically assisted vaginal route.

Example:

A patient with a 200-gram uterus and benign fibroids undergoes LAVH. The surgeon performs laparoscopic mobilization of the uterus and ligaments, then removes the uterus and cervix vaginally. Operative documentation confirms both components.

Minimally Invasive Surgical Approach:

When the laparoscopic detachment is completed before vaginal extraction, without conversion to a fully abdominal hysterectomy.

Uterine Size Criteria:

The procedure is appropriate only for uterine weights ≤250 grams, confirmed either intraoperatively or by pathology.

Applicable Modifiers for CPT Code 58550

The following modifiers may be used with CPT code 58550 when appropriate:

Modifier 22 – Increased Procedural Services

Used when the procedure requires significantly more time or effort than usual due to adhesions, abnormal anatomy, or complex dissection.

Modifier 51 – Multiple Procedures

Applicable if CPT 58550 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 encounter.

Modifier 62 – Two Surgeons

Reported when two surgeons share responsibility for 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 58550 – Billing & Reimbursement

To ensure proper reimbursement for CPT code 58550, follow these key steps:

Justify Medical Necessity:

Document the patient’s diagnosis (e.g., fibroids, adenomyosis, abnormal uterine bleeding) and the clinical rationale for performing a laparoscopically assisted vaginal hysterectomy.

Use Accurate ICD-10 Codes:

Pair CPT 58550 with diagnosis codes that reflect the uterine condition and the clinical indication for surgery.

Confirm Surgical Details:

The operative report should clearly document:

• Uterine weight ≤250 grams
• Laparoscopic dissection of ligaments, pedicles, and uterine mobilization
• Vaginal removal of uterus and cervix
• Intraoperative findings and any complications

Detailed Documentation:

Ensure that the operative note includes all steps of both the laparoscopic and vaginal components, intraoperative findings, hemostasis, and closure.

Reimbursement Considerations:

Reimbursement varies by payer, place of service, and geographic location. Accurate documentation is critical to differentiate CPT 58550 from fully laparoscopic or abdominal hysterectomy codes and to ensure payer compliance and proper reimbursement.

BillingFreedom: Expert Support for Laparoscopically Assisted Vaginal Hysterectomy

Even procedures that seem straightforward, like a laparoscopically assisted vaginal hysterectomy (LAVH) for a uterus ≤250 g, involve critical documentation and coding decisions. The combination of laparoscopic and vaginal approaches requires precise operative notes, correct code selection, and appropriate modifier application to ensure compliance and maximize reimbursement.

BillingFreedom provides specialized OBGYN medical billing services in Kansas to handle these procedures efficiently. Our expert team reviews operative reports, confirms uterine weight and approach, applies the correct modifiers, and prepares claims that meet payer requirements. This allows physicians to focus on patient care while minimizing denials and optimizing revenue.

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