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Laparoscopically assisted vaginal hysterectomy (LAVH) for a uterus larger than 250 g that includes removal of adnexal structures (fallopian tubes and/or ovaries) requires precise operative documentation and accurate coding to ensure correct reimbursement. CPT 58554 encompasses the combined laparoscopic mobilization with vaginal extraction of the enlarged uterus and adnexa.

CPT Code 58554 – Description

The official definition of CPT code 58554 is:

“Laparoscopy, surgical, with vaginal hysterectomy, uterus greater than 250 grams; with removal of tube(s) and/or ovary(s).”

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

The scope of CPT 58554 includes laparoscopic entry and dissection of uterine ligaments, mobilization and ligation of adnexal structures (uni- or bilateral), vaginal extraction of the uterus and adnexa, and closure of the vaginal cuff and laparoscopic port sites.

Scenarios Where CPT Code 58554 Is Applicable

You would bill CPT code 58554 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 adnexal structures.

Example:

A patient with a 300-gram uterus and unilateral ovarian cyst undergoes LAVH. The surgeon performs laparoscopic mobilization of ligaments 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 laparoscopic detachment precedes vaginal extraction, without conversion to a fully abdominal hysterectomy.

Documentation of Complexity:

The code is appropriate when adhesions, anatomical variations, or technical challenges increase procedural complexity, and documentation must clearly reflect these factors.

Applicable Modifiers for CPT Code 58554

The following modifiers may be used with CPT code 58554 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 58554 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 58554 – Billing & Reimbursement

To ensure proper reimbursement for CPT code 58554, follow these key steps:

Justify Medical Necessity:

Document the patient’s diagnosis (e.g., fibroids, adenomyosis, abnormal uterine bleeding, adnexal pathology) and the clinical rationale for performing a laparoscopically assisted vaginal hysterectomy with adnexal removal for a uterus >250 grams.

Use Accurate ICD-10 Codes:

Pair CPT 58554 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 uterine and adnexal attachments
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 58554 from LAVH without adnexal removal (CPT 58553) and to ensure payer compliance and proper reimbursement.

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