In the field of medical billing and coding, CPT codes hysterectomy are essential for accurately reporting surgical procedures involving the removal of the uterus. A hysterectomy can be performed for various medical reasons, including uterine fibroids, cancer, endometriosis, abnormal bleeding, or pelvic organ prolapse. Since there are multiple surgical approaches, it’s crucial to understand the correct Current Procedural Terminology (CPT) codes for proper documentation, billing, and insurance claims.
This comprehensive guide will cover the types of hysterectomy procedures, their associated CPT codes, and key considerations for coders and healthcare providers.
What is a Hysterectomy?
A hysterectomy is a surgical procedure in which the uterus is removed, either partially or completely. Depending on the patient’s condition, the surgery may also involve the removal of related structures such as the cervix, fallopian tubes, or ovaries.
The main types of hysterectomies include:
- Total Hysterectomy – Removal of the uterus and cervix.
- Subtotal (Supracervical) Hysterectomy – Removal of the uterus but leaving the cervix intact.
- Radical Hysterectomy – Removal of the uterus, cervix, part of the vagina, and surrounding tissues, often for cancer treatment.
CPT Codes for Hysterectomy
Here is a breakdown of common CPT codes for hysterectomy based on surgical approach:
1. Abdominal Hysterectomy (Open Surgery)
- 58150 – Total abdominal hysterectomy (TAH), with or without removal of tubes and ovaries.
- 58152 – Total abdominal hysterectomy with removal of tubes and ovaries plus lymph node sampling.
2. Vaginal Hysterectomy
- 58260 – Vaginal hysterectomy (uterus 250g or less).
- 58262 – Vaginal hysterectomy with removal of tubes and/or ovaries.
- 58291 – Radical vaginal hysterectomy with lymph node sampling.
3. Laparoscopic Hysterectomy
- 58550 – Laparoscopic supracervical hysterectomy.
- 58552 – Laparoscopic total hysterectomy (uterus ≤ 250g) with or without tubes/ovaries.
- 58570 – Laparoscopic total hysterectomy (uterus > 250g).
- 58571 – Laparoscopic total hysterectomy with removal of tubes and/or ovaries.
- 58573 – Laparoscopic radical hysterectomy.
4. Radical Hysterectomy (Cancer-related)
- 58210 – Radical abdominal hysterectomy, including lymph nodes.
- 58240 – Pelvic exenteration (removal of uterus, cervix, vagina, bladder, and rectum in advanced cancer cases).
Key Coding Considerations
- Documentation is Vital – Coders must carefully review operative reports to ensure the correct CPT code is selected based on approach, weight of the uterus, and whether additional structures were removed.
- Modifiers – In some cases, modifiers (e.g., -52 for reduced services, -22 for increased complexity) may be necessary.
- ICD-10 Codes Pairing – Ensure the CPT code is paired with the correct diagnosis (such as uterine fibroids, carcinoma, or endometriosis).
- Insurance Coverage – Some payers may have specific requirements, making accuracy critical for reimbursement.
Why Correct CPT Coding for Hysterectomy Matters
Accurate coding ensures:
- Proper reimbursement for healthcare providers.
- Avoidance of claim denials.
- Compliance with insurance and regulatory guidelines.
- Clear documentation of patient care.
For medical coders, mastering CPT codes hysterectomy is essential for reducing errors and streamlining the billing process.
Choosing High-Quality Surgical Instruments
While coding ensures accurate billing, the success of a hysterectomy also relies heavily on the quality of surgical instruments. At Meister Surgical, we provide stainless steel surgical instruments designed for precision, safety, and durability in gynecological and general surgeries. From scalpels to retractors and forceps, our tools meet international quality standards.
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Conclusion
Understanding CPT codes hysterectomy is crucial for medical coders, billing specialists, and healthcare providers. Each surgical approach—abdominal, vaginal, laparoscopic, or radical—has specific codes that must be carefully applied based on documentation. Proper coding not only ensures reimbursement but also maintains compliance with medical regulations.
For healthcare professionals seeking premium surgical instruments to support gynecological procedures, Meister Surgical is a trusted partner.