CPT Code 58674 Laparoscopic Radiofrequency Ablation of Uterine Fibroid

Symptomatic uterine fibroids can cause heavy menstrual bleeding, pelvic pain, and pressure symptoms, impacting quality of life and fertility. CPT 58674 is used for laparoscopic ablation of uterine fibroids using radiofrequency energy, incorporating real-time intraoperative ultrasound guidance and monitoring. Accurate coding and documentation are essential for OBGYN practices to maximize reimbursement and ensure compliance.

CPT Code 58674 – Description

The official definition of CPT code 58674 is:

“Laparoscopy, surgical, ablation of uterine fibroid(s) including intraoperative ultrasound guidance and monitoring, radiofrequency.”

Key points:

• Minimally invasive laparoscopic procedure.
• Fibroid ablation using radiofrequency energy.
• Includes real-time intraoperative ultrasound for targeting and monitoring.
• Uterus is preserved.
• Not for transcervical ablation (58580), hysteroscopic myomectomy (58561), or open/laparoscopic myomectomy (58571/58575).

Scenarios Where CPT Code 58674 Is Applicable

You would bill CPT code 58674 in the following situations:

Symptomatic Fibroid Ablation via Laparoscopy:

When a patient has fibroids causing heavy bleeding, pelvic pain, or pressure symptoms, and the surgeon performs laparoscopic radiofrequency ablation with ultrasound guidance to target and monitor fibroids while preserving the uterus.

Examples:

• A 38-year-old patient with symptomatic intramural fibroids undergoes laparoscopic radiofrequency ablation using intraoperative ultrasound to guide treatment.
• Multiple small uterine fibroids are identified and ablated laparoscopically with preservation of surrounding uterine tissue.

Applicable Modifiers for CPT Code 58674

Modifier 22 – Increased Procedural Services

Use if the procedure is technically challenging due to multiple fibroids, unusual anatomy, or adhesions.

Modifier 59 – Distinct Procedural Service

Applicable if another laparoscopic procedure is performed during the same session and is clinically distinct from the fibroid ablation.

CPT Code 58674 – Billing & Reimbursement

To ensure proper reimbursement for CPT code 58674, follow these key steps:

Justify Medical Necessity:

Document the presence of symptomatic fibroids, clinical symptoms, and the rationale for using laparoscopic radiofrequency ablation.

Use Accurate ICD-10 Codes:

Examples include:

• D25.0 – Submucous leiomyoma of uterus
• D25.1 – Intramural leiomyoma of uterus
• D25.9 – Leiomyoma of uterus, unspecified

Confirm Procedural Details:

The operative note should clearly document:

• Laparoscopic entry and port placement
• Identification of fibroids using intraoperative ultrasound
• Delivery of radiofrequency energy and monitoring
• Preservation of uterine tissue
• Any intraoperative complications or technical challenges

Reimbursement Considerations:

Accurate documentation ensures payers recognize the minimally invasive nature of the procedure, differentiates it from transcervical, hysteroscopic, or open myomectomy procedures, and supports appropriate reimbursement while minimizing claim denials.

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