Total laparoscopic hysterectomy (TLH) for a uterus greater than 250 grams is a minimally invasive surgical procedure used to remove the uterus, including the cervix, through small abdominal incisions.

This approach reduces recovery time, blood loss, and postoperative pain compared to open surgery. Accurate coding and documentation are essential to ensure proper reimbursement and reflect the complexity of the procedure, particularly in cases involving large uteri or additional surgical challenges.

CPT Code 58572 – Description

The official definition of CPT code 58572 is:

“Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g.”

This code describes a therapeutic laparoscopic procedure in which the uterus, including the cervix, is completely removed. The procedure involves laparoscopic entry into the abdominal cavity using trocars and specialized instruments, colpotomy, closure of the vaginal cuff, and lysis of minor adhesions if necessary. Removal of fallopian tubes or ovaries is not included in this code (use CPT 58573 if adnexa are removed).

Documentation must clearly confirm the uterine weight >250 grams to differentiate from CPT 58570 for smaller uteri.

Scenarios Where CPT Code 58572 Is Applicable

You would bill CPT code 58572 in the following situations:

Symptomatic Uterus >250 g:

When a patient has a large uterus due to benign conditions such as fibroids, adenomyosis, or abnormal uterine bleeding, and a total laparoscopic hysterectomy is performed.

Example:

A patient with multiple large fibroids resulting in a uterine weight of 300 g undergoes a laparoscopic total hysterectomy. Operative notes confirm complete uterine removal, colpotomy, vaginal cuff closure, and minor adhesiolysis.

Technical Complexity:

If minor adhesions or difficult anatomy are present, detailed documentation is needed to justify increased procedural complexity or extended operative time.

Applicable Modifiers for CPT Code 58572

The following modifier may be used with CPT code 58572 when appropriate:

Modifier 22 – Increased Procedural Services

Applicable if the procedure requires additional effort due to extensive adhesions, difficult anatomy, or operative time exceeding standard expectations. Documentation must clearly justify the increased service.

No other modifiers are routinely required for this code unless payer-specific instructions indicate otherwise.

CPT Code 58572 – Billing & Reimbursement

To ensure proper reimbursement for CPT code 58572, follow these key steps:

Justify Medical Necessity:

Document the clinical indication for total hysterectomy, including symptomatic fibroids, adenomyosis, or abnormal bleeding, and uterine weight >250 g.

Use Accurate ICD-10 Codes:

Pair CPT 58572 with diagnosis codes reflecting the underlying benign condition, such as D25.x (fibroids) or N80.x (adenomyosis).

Confirm Procedural Details:

The operative report should clearly document:

• Laparoscopic entry and abdominal access
• Complete removal of the uterus including the cervix
• Colpotomy and closure of the vaginal cuff
• Lysis of minor adhesions if applicable
• Uterine weight or pathology confirmation

Detailed Documentation:

Include any operative challenges, adhesions, or technical complexity to support modifier 22 and ensure payer compliance.

Reimbursement Considerations:

CPT 58572 reimbursement depends on documentation showing uterine size, laparoscopic approach, and any increased procedural complexity. Proper coding differentiates this procedure from smaller uterus hysterectomies and ensures accurate payer recognition and payment.

BillingFreedom – Expert OBGYN Medical Billing Services

BillingFreedom specializes in OBGYN medical billing for complex procedures such as CPT 58572. Our team stays constantly updated on AMA CPT codes, NCCI edits, and payer-specific rules to ensure:

• Coding accuracy: consistently >98%
• Denial rate: <3%
• First-pass acceptance rate: 97–99%
• Revenue impact: maximized reimbursement and improved cash flow

At BillingFreedom, we carefully review operative notes, verify CPT and modifier selection, and ensure documentation reflects procedural complexity. Partnering with BillingFreedom’s OBGYN medical billing services in Connecticut minimizes claim denials, reduces administrative burden, and enhances financial performance for practices performing laparoscopic hysterectomies.

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