CPT Code 58611 Complete Guide to Tubal Ligation Performed During Cesarean Delivery

CPT 58611 is used when a permanent sterilization procedure is performed at the same time as a cesarean delivery or another open intra-abdominal surgery. Instead of scheduling a separate sterilization procedure after childbirth, the surgeon performs tubal ligation during the same operative session, adding very little extra anesthesia risk or recovery time for the patient.

CPT Code 58611 – Description

The official definition of CPT code 58611 is:

“+Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra-abdominal surgery (not a separate procedure) (List separately in addition to code for primary procedure).”

Key points:

• This is an add-on code (+) and cannot be reported alone.
• It applies only when tubal ligation is performed during cesarean delivery or another open intra-abdominal surgery.
• May be unilateral or bilateral; the code does not change.
• Captures only the additional sterilization work performed alongside the primary procedure.

Do not use this code for:

• Postpartum sterilization after vaginal delivery (58605)
• Interval tubal ligation (58600)
• Laparoscopic sterilization (58670, 58671)

Scenarios Where CPT Code 58611 Is Applicable

You would bill CPT code 58611 in the following situations:

Tubal Ligation During Cesarean Delivery:

When a patient requests permanent sterilization and the procedure is performed during cesarean delivery.

Example:

A 28-year-old patient undergoes a cesarean section (CPT 59514). During the same surgery, bilateral tubal ligation is performed. CPT 58611 is added to report the sterilization work.

Tubal Ligation During Other Open Abdominal Surgery:

If tubal ligation is performed during another open intra-abdominal procedure, such as hysterectomy or myomectomy, 58611 can be appended. Documentation must specify that the procedure is done concurrently with the primary surgery.

Applicable Modifiers for CPT Code 58611

Modifier 22 – Increased Procedural Services

Use if the tubal ligation required additional effort due to adhesions, anatomical variations, or other technical challenges. Documentation must justify the increased service.

Other routine modifiers are generally not required, as this is an add-on code and is inherently reported with a primary procedure.

CPT Code 58611 – Billing & Reimbursement

To ensure proper reimbursement for CPT code 58611, follow these key steps:

Justify Medical Necessity:

Document that tubal ligation is performed during cesarean delivery or open intra-abdominal surgery, with patient consent.

Use Accurate ICD-10 Codes:

Pair CPT 58611 with the primary procedure diagnosis, such as:

• O82.0 – Single delivery by cesarean section
• Z30.2 – Encounter for sterilization

Confirm Procedural Details:

The operative note should clearly document:

• Primary procedure (cesarean or open surgery)
• Tubal ligation performed concurrently
• Unilateral or bilateral status
• Any intraoperative complications or technical challenges

Detailed Documentation:

Include all operative steps, patient consent, and postoperative monitoring to support the add-on code.

Reimbursement Considerations:

CPT 58611 is always reported in addition to the primary procedure. Accurate documentation ensures payers recognize the added sterilization work, prevents denials, and supports proper reimbursement.

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