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CPT Code 58571 Laparoscopy, Surgical; Total Hysterectomy, Uterus Greater than 250g

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Accurate procedural coding for gynecologic surgeries is essential for proper reimbursement and compliance. CPT 58571 represents a laparoscopic total hysterectomy performed for a uterus weighing more than 250 grams.

This major surgical procedure is used to treat conditions such as fibroids, abnormal bleeding, or pelvic pain when conservative management fails. Due to the complexity of operating on a larger uterus, this code typically involves longer operative time, increased difficulty, and higher reimbursement compared to CPT 58570.

CPT Code 58571 – Description of the Procedure

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

This procedure involves the complete laparoscopic removal of the uterus and cervix when the uterine specimen weighs more than 250 grams.

The surgeon performs the operation through small incisions using a laparoscope and specialized instruments to detach and remove the enlarged uterus.

Key Points to Remember:

  • Approach: Laparoscopic (minimally invasive).
  • Extent: Total hysterectomy (uterus and cervix).
  • Uterine weight: More than 250 grams after removal.
  • Purpose: Therapeutic surgery for a symptomatic, enlarged uterus or pathology.

The procedure demands careful dissection and hemostasis due to the increased uterine size and limited visualization space in the pelvis.

When to Use CPT 58571

Use CPT 58571 when the uterus being removed laparoscopically weighs over 250 grams and the entire uterus (with cervix) is excised.

Common Clinical Indications Include:

  • Large or multiple uterine fibroids (leiomyomas)
  • Symptomatic uterine enlargement
  • Abnormal uterine bleeding unresponsive to medical treatment
  • Adenomyosis or endometriosis involving an enlarged uterus
  • Benign uterine masses requiring surgical management

Do not report CPT 58571 if:

  • The uterus weighs 250 grams or less (use 58570).
  • A supracervical hysterectomy is performed (use 58541 or 58542).
  • A radical dissection for malignancy is performed (use 58573).
  • The procedure is done through an abdominal or vaginal approach (use 58150 or 58260–58262).

Coding Guidelines and Billing Rules

CPT 58571 should be reported once per surgical session, representing the entire laparoscopic total hysterectomy.

Bundled components:

  • Laparoscopic entry and closure
  • Detachment of the uterus and cervix
  • Removal of the uterus through vaginal or laparoscopic technique
  • Minor lysis of adhesions and hemostasis

Separate procedures:

If the surgeon also performs salpingectomy, oophorectomy, or lysis of extensive adhesions, these should be reported separately (e.g., 58661, 58740) with modifier 51 for multiple procedures.

Global period: 90 days

Setting: Typically, a hospital or an ambulatory surgical center (ASC)

Prior authorization is often required, especially for benign indications, as documentation of failed medical management supports approval.

Reimbursement and Coverage Information

Reimbursement for CPT 58571 generally exceeds that of 58570 due to the increased complexity of removing a larger uterus.

Approximate Medicare National Payment Rates:

  • Physician (facility): $1,050–$1,300
  • Hospital Outpatient Facility: $1,900–$2,400
  • ASC Payment: $1,600–$2,100
  • Global period: 90 days

Common ICD-10 Codes Supporting Medical Necessity:

  • D25.1 – Intramural leiomyoma of uterus
  • D25.2 – Subserosal leiomyoma of the uterus
  • N93.9 – Abnormal uterine bleeding, unspecified
  • N85.9 – Noninflammatory disorder of uterus, unspecified
  • N80.9 – Endometriosis, unspecified

Always verify payer-specific guidelines, as coverage for hysterectomy procedures can depend on the indication and documentation of prior conservative treatment.

Modifier Use

Appropriate modifier selection ensures claim accuracy and reduces denials.

  • Modifier 51 – Multiple procedures during the same operative session.
  • Modifier 52 – Reduced services (if procedure partially completed).
  • Modifier 59 – Distinct procedural service, when justified.
  • Modifiers 54, 55, 56 – For split surgical care (surgical, postoperative, or preoperative management only).
  • Modifier 22 – For unusually complex cases due to a large uterus or extensive adhesions; must be supported by an operative note.

Documentation Requirements

Detailed and specific documentation supports coding accuracy and compliance:

  • Preoperative diagnosis and indication (fibroids, bleeding, pain, etc.)
  • Surgical approach: Laparoscopic, total hysterectomy
  • Uterine weight: Must exceed 250 grams (confirmed by pathology report)
  • Organs removed: Uterus ± cervix ± adnexa (if applicable)
  • Intraoperative findings: Adhesions, endometriosis, or anomalies
  • Hemostasis and specimen removal details
  • Postoperative care and instructions

Clear operative reports help justify the selected CPT code and modifiers, minimizing payer denials or audit risks.

Example Scenarios

Scenario 1 – Large Fibroid Uterus

A 48-year-old patient presents with heavy bleeding and pelvic pressure due to a fibroid uterus. A laparoscopic total hysterectomy is performed, and the uterus weighs 320 grams.

→ Report CPT 58571.

Scenario 2 – Laparoscopic Hysterectomy with Bilateral Salpingectomy

A 42-year-old with abnormal bleeding undergoes a laparoscopic total hysterectomy (uterus 270 grams) with bilateral salpingectomy.

→ Report CPT 58571 and 58661 with modifier 51 for multiple procedures.

Scenario 3 – Incomplete Laparoscopic Procedure Converted to Open

A laparoscopic total hysterectomy is initiated, but due to severe adhesions and large uterine size, the procedure is converted to an open abdominal hysterectomy.

→ Report 58150 (open hysterectomy) and append modifier 52 to 58571 if partial laparoscopic work was completed.

These examples highlight how documentation of uterine weight, surgical approach, and procedure completion determines the correct code and modifier usage.

Why Choose BillingFreedom for OBGYN Billing

Laparoscopic hysterectomies are complex surgeries that require precise coding, accurate modifier use, and clear operative documentation. Errors can result in underpayment or claim denials.

At BillingFreedom, our team of certified coders specializes in OBGYN medical billing services, ensuring your surgical claims are clean, compliant, and paid promptly. We stay up to date with the latest AAPC and CMS coding guidelines, so you can focus on patient care while we handle the billing complexities.

Our services include:

  • Expert review of operative reports for code accuracy
  • Modifier and global period management
  • Denial prevention and appeals support
  • Streamlined claim submission and faster payments

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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