CPT Code 58553 Laparoscopically Assisted Vaginal Hysterectomy (Uterus >250 g with Adnexal Removal)

Laparoscopically assisted vaginal hysterectomy (LAVH) with adnexal removal for a uterus >250 g requires precision in both surgery and documentation. Removal of adnexal structures, along with laparoscopic mobilization and vaginal extraction of the uterus, increases procedural complexity and impacts coding and reimbursement.

Detailed operative notes and correct modifier use are essential for claim approval. Partnering with OBGYN medical billing services ensures accurate coding, proper modifier application, and optimized reimbursement while reducing administrative burden.

CPT Code 58553 – Description

The official definition of CPT code 58553 is:

“Laparoscopically assisted vaginal hysterectomy, uterus greater than 250 grams, including removal of adnexal structures (ovaries and/or fallopian tubes).”

This code describes a minimally invasive procedure in which the surgeon performs laparoscopic mobilization of the uterus and adnexa, including detachment of ligaments and vascular pedicles, followed by vaginal removal of the uterus and adnexal structures. Both the laparoscopic and vaginal components must be documented in the operative note to justify the use of this code.

The scope of CPT 58553 includes laparoscopic abdominal entry, dissection of uterine and adnexal attachments, detachment of ligaments and vascular pedicles, vaginal removal of uterus and adnexa, and closure of the vaginal cuff and laparoscopic port sites.

Scenarios Where CPT Code 58553 Is Applicable

You would bill CPT code 58553 in the following situations:

Large Uterus with Adnexal Removal:

When a patient has a uterus >250 grams and requires laparoscopically assisted vaginal removal with removal of one or both ovaries and/or fallopian tubes.

Example:

A patient with a 300-gram uterus and ovarian cysts undergoes LAVH. The surgeon performs laparoscopic mobilization of the uterus and adnexa, followed by vaginal removal of the uterus and adnexa. Operative documentation confirms uterine weight, adnexal removal, and both procedural components.

Minimally Invasive Surgical Approach:

When both laparoscopic detachment and vaginal extraction are completed without conversion to an open abdominal hysterectomy.

Documentation of Complexity:

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

Applicable Modifiers for CPT Code 58553

The following modifiers may be used with CPT code 58553 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 58553 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 58553 – Billing & Reimbursement

To ensure proper reimbursement for CPT code 58553, follow these key steps:

Justify Medical Necessity:

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

Use Accurate ICD-10 Codes:

Pair CPT 58553 with diagnosis codes that reflect the uterine and adnexal conditions and clinical indications for surgery.

Confirm Surgical Details:

The operative report should clearly document:

• Uterine weight >250 grams
• Removal of adnexal structures (ovaries and/or fallopian tubes)
• Laparoscopic detachment of ligaments and adnexa
• Vaginal removal of uterus and adnexa
• 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 58553 from uterus-only LAVH (CPT 58552) and to ensure payer compliance and proper reimbursement.

BillingFreedom: Expert Support for LAVH with Adnexal Removal (Uterus >250 g)

Handling a laparoscopically assisted vaginal hysterectomy with adnexal removal for a uterus exceeding 250 g involves complex surgical and documentation challenges. Accurate coding requires recording uterine weight, laparoscopic steps, vaginal removal, and adnexal excision. Any gaps in documentation can lead to claim denials or reduced reimbursement.

BillingFreedom offers specialized OBGYN medical billing services in Idaho to simplify this process. Our team reviews operative notes, ensures correct coding and modifier use, and prepares compliant claims to maximize reimbursement. Physicians can focus on patient care while BillingFreedom handles the administrative and coding complexities. 

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