CPT Code 58570 Laparoscopy, Surgical; Total Hysterectomy, Uterus 250g or Less

Accurate coding of laparoscopic gynecologic surgeries is vital for correct reimbursement and compliance. CPT 58570 represents a laparoscopic total hysterectomy for a uterus weighing 250 grams or less.

This is a common minimally invasive gynecologic surgery performed for benign conditions such as fibroids, abnormal bleeding, endometriosis, or chronic pelvic pain when conservative treatment fails.

Understanding how to code and document this procedure correctly is key to reducing denials and ensuring the provider receives proper payment for the complexity of care involved.

CPT Code 58570 – Description of the Procedure

Official CPT Definition: “Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less.”

This procedure involves the complete removal of the uterus (with or without cervix) through a laparoscopic approach. The surgeon makes small incisions to insert a laparoscope and surgical instruments to detach the uterus from supporting structures and remove it via the vagina or laparoscopic ports.

CPT 58570 differs from other hysterectomy codes in that it is:

• Limited to a uterine weight ≤250 grams (a smaller uterus).
• Performed laparoscopically, not via abdominal or vaginal approach.
• Used for total hysterectomy (entire uterus, not supracervical).

When to Use CPT 58570

This code applies when a laparoscopic total hysterectomy is performed and the uterine specimen weighs 250 grams or less. The weight is determined after removal.

Typical clinical indications include:

• Uterine fibroids (leiomyomas)
• Abnormal uterine bleeding unresponsive to medical therapy
• Endometriosis or adenomyosis
• Pelvic pain related to uterine pathology
• Precancerous lesions requiring hysterectomy
• Benign uterine tumors or hypertrophy

Do not report CPT 58570 when:

• The uterus weighs more than 250 grams - use CPT 58571.
• A supracervical hysterectomy is performed - use CPT 58541 or 58542.
• The hysterectomy is performed vaginally - use CPT 58260–58262.
• The procedure involves radical dissection for cancer - use CPT 58573.

Coding Guidelines and Billing Rules

Follow these best practices to ensure accurate reporting of CPT 58570:

• Report 58570 once per operative session per patient.
• Includes: laparoscopic entry, inspection, and removal of the uterus (with or without cervix).
• Bundled services: lysis of minor adhesions, control of minor bleeding, or specimen retrieval.
• If additional laparoscopic procedures (e.g., salpingectomy or oophorectomy) are performed, report them separately with modifier 51.
• Global period: 90 days under Medicare guidelines.
• Prior authorization: Often required for non-emergency hysterectomies; include documentation of failed medical therapy.

Reimbursement and Coverage Information

Reimbursement for CPT 58570 varies based on payer and location, but it generally reflects the complexity of laparoscopic surgery.

Approximate Medicare Rates:

• Physician (non-facility): $950–$1,200
• Facility (hospital outpatient): $1,600–$2,000
• ASC Payment: $1,400–$1,800
• Global period: 90 days

ICD-10 codes supporting medical necessity include:

• D25.0 – Submucous leiomyoma of uterus
• N93.9 – Abnormal uterine and vaginal bleeding, unspecified
• N80.9 – Endometriosis, unspecified
• N85.9 – Noninflammatory disorder of uterus, unspecified
• N81.9 – Female genital prolapse, unspecified

Payers may request imaging, pathology, or history of prior therapies to confirm necessity before authorizing or paying for the procedure.

Modifier Use

Modifiers clarify distinct services, multiple procedures, or shared care situations:

• Modifier 51 – Multiple procedures during the same session (e.g., hysterectomy + salpingectomy).
• Modifier 52 – Reduced services (if procedure is incomplete).
• Modifier 59 – Distinct procedural service (used cautiously with documentation).
• Modifiers 54, 55, 56 – When care is split between different providers.
• Modifier 22 – Increased procedural service for complex anatomy or adhesions.

Documentation Requirements

For accurate billing and audit defense, operative notes should include:

• Indication for surgery (e.g., fibroids, abnormal bleeding, etc.).
• Uterine weight (≤250 grams documented).
• Surgical approach and steps (trocar placement, detachment, specimen removal).
• Organs removed (uterus ± cervix).
• Findings, complications, and hemostasis.
• Pathology confirmation and postoperative instructions.

Detailed and precise documentation ensures the correct CPT selection and supports medical necessity under payer rules.

Example Scenarios

Scenario 1 – Fibroid Uterus with Chronic Bleeding

A 45-year-old patient with menorrhagia undergoes a laparoscopic total hysterectomy for a uterus weighing 180 grams. The procedure is completed without complications.

→ Report CPT 58570.

Scenario 2 – Laparoscopic Hysterectomy with Oophorectomy

A patient with endometriosis undergoes a laparoscopic total hysterectomy (uterus 220 grams) and bilateral oophorectomy.

→ Report CPT 58570 and 58661 with modifier 51 for multiple procedures.

Scenario 3 – Incomplete Procedure Due to Adhesions

A surgeon begins a laparoscopic hysterectomy but must convert to open due to severe adhesions.

→ Report CPT 58570 with modifier 52 (reduced service) or convert to open code 58150, depending on documentation.

These examples show how accurate CPT selection and modifier usage rely heavily on operative details and uterine weight documentation.

Why Choose BillingFreedom for OBGYN Billing

Laparoscopic hysterectomy coding involves intricate details like uterine weight, surgical approach, and concurrent procedures - all of which must be captured correctly for clean claim submission.

At BillingFreedom, we specialize in OBGYN medical billing services, helping practices avoid denials, ensure compliance, and receive prompt reimbursement. Our certified coders stay current with AAPC and CMS coding updates, ensuring your hysterectomy claims are accurate and audit-ready.

With BillingFreedom, you gain:

• Precise CPT and modifier application.
• Denial prevention and faster payments.
• End-to-end revenue cycle management for surgical claims.
• Confidence in compliance and documentation support.

For more details about our exceptional medical billing services, 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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