CPT Code 58552 Laparoscopically Assisted Vaginal Hysterectomy (Uterus >250 g)

Laparoscopic procedures for larger uteri or complex uterine pathology demand precision not only in surgery but also in documentation and billing. Accurate recording of operative steps, approach, and uterine size is critical for smooth reimbursement. Partnering with specialized OBGYN medical billing services ensures claims reflect procedural complexity, comply with payer requirements, and minimize the risk of denials, allowing physicians to focus on patient care.

CPT Code 58552 – Description

The official definition of CPT code 58552 is:

“Laparoscopically assisted vaginal hysterectomy, uterus greater than 250 grams.”

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

The scope of CPT 58552 includes laparoscopic abdominal entry and port placement, detachment of uterine ligaments and vascular pedicles, mobilization for vaginal extraction, removal of the uterus and cervix vaginally, and closure of the vaginal cuff and laparoscopic ports.

Scenarios Where CPT Code 58552 Is Applicable

You would bill CPT code 58552 in the following situations:

Large 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 300-gram uterus with fibroids undergoes LAVH. The surgeon performs laparoscopic mobilization of ligaments and vascular pedicles, then removes the uterus and cervix vaginally. Operative documentation confirms both components and uterine weight.

Minimally Invasive Surgical Approach:

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

Documentation of Complexity:

The code is appropriate when adhesions, anatomical variations, or other intraoperative challenges increase procedural complexity.

Applicable Modifiers for CPT Code 58552

The following modifiers may be used with CPT code 58552 when appropriate:

Modifier 22 – Increased Procedural Services

Used when the procedure requires significantly more time or effort due to adhesions, abnormal anatomy, or large uterine size.

Modifier 51 – Multiple Procedures

Applicable if CPT 58552 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 58552 – Billing & Reimbursement

To ensure proper reimbursement for CPT code 58552, follow these key steps:

Justify Medical Necessity:

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

Use Accurate ICD-10 Codes:

Pair CPT 58552 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 detachment of ligaments, vascular pedicles, and uterus mobilization
• Vaginal removal of uterus and cervix
• Any adnexal removal (if applicable)
• Intraoperative challenges, adhesions, or anatomical variations

Detailed Documentation:

Ensure the operative note includes all steps of both the laparoscopic and vaginal components, hemostasis, closure, and any complications.

Reimbursement Considerations:

Reimbursement varies by payer, place of service, and geographic location. Accurate documentation is critical to differentiate CPT 58552 from smaller-uterus LAVH (CPT 58550) and to ensure payer compliance and proper reimbursement.

BillingFreedom: Expert Support for Laparoscopically Assisted Vaginal Hysterectomy (Uterus >250 g)

Managing a laparoscopically assisted vaginal hysterectomy for a uterus exceeding 250 g involves complex operative steps, precise documentation, and correct coding to ensure compliance and maximize reimbursement. From laparoscopic mobilization of ligaments and vascular pedicles to vaginal removal of the uterus and cervix, every detail impacts coding accuracy.

BillingFreedom provides specialized OBGYN medical billing services in Iowa to streamline this process. Our team reviews operative reports, confirms uterine weight, ensures proper coding and modifier application, and prepares compliant claims for optimal reimbursement. This support allows physicians to focus entirely on patient care while minimizing claim denials and administrative burden. Explore our full guideline for best practices, documentation tips, and reimbursement insights for CPT 58552.

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