CPT Code 58150: Total Abdominal Hysterectomy (TAH)

CPT code 58150 covers total abdominal hysterectomy, including uterus and cervix removal via abdominal incision, often for fibroids or gynecologic cancers.

Use Code

What is the CPT code 58150?

CPT Code 58150 is used to report a total abdominal hysterectomy, a surgical procedure involving the complete removal of the uterus (including the corpus) and cervix through an abdominal incision. This procedure may be performed alone or alongside the removal of one or both fallopian tubes and/or ovaries, though these additional removals are not required for the use of this code.

Typically, CPT 58150 is utilized in cases where a patient is being treated for conditions such as uterine fibroids, endometriosis, or gynecological cancers. As a core part of the hysterectomy procedures defined by the American Medical Association (AMA), 58150 plays a critical role in coding, billing, and documentation for abdominal surgical treatment of these reproductive health conditions. The 58150 CPT code is frequently referenced by healthcare providers performing hysterectomy for various gynecological conditions.

In clinical billing, various modifiers can be added to CPT 58150 to clarify unique circumstances. For example, Modifier 22 may be used for unusually complex cases, while Modifier 52 may apply if the procedure is partially reduced. These modifiers ensure transparency in procedure reporting and help align documentation with payer requirements.

CPT Code 58150 documentation requirements

Accurate documentation is essential when reporting CPT Code 58150, which covers a total abdominal hysterectomy. Thorough and compliant records help ensure proper coding, billing, and reimbursement, while also minimizing claim denials. Proper billing depends on correctly detailing the procedure and services rendered during the surgery.

Operative report: Document removal of uterus and cervix via abdominal incision; include any fallopian tube/ovary removal—do not bill separately. This ensures clarity about the procedure performed within the abdomen.
Pre-op notes: Include diagnosis (e.g., fibroids, endometriosis, cancer) and justify medical necessity for the cpt code.
Pathology reports: Attach pathology findings that support the diagnosis and treatment of gynecological conditions.
Post-op care: Note recovery progress, complications, and follow-up care to describe the full scope of the procedure.
Patient demographics: Ensure accurate information for claim processing and provider records.
ICD-10 linkage: Match appropriate diagnosis codes to CPT Code 58150 for proper billing and reimbursement.
Modifier use: Justify any modifiers (22, 51, 52, 59, 78) with supporting documentation from the physician.
Payer policy compliance: Follow insurance and MAC-specific documentation guidelines to ensure proper billing for the procedure.
Avoid unbundling: Do not separately report services bundled in CPT Code 58150, such as removal of fallopian tubes and ovaries when included.

CPT Code 58150 billing guidelines

Include operative report, pre/post-op notes, pathology reports, patient demographics, and ICD-10 codes that support medical necessity.
Clearly justify the need for surgery (e.g., fibroids, endometriosis, cancer, prolapse).
Do not bill separately for salpingectomy or oophorectomy—these are included in CPT 58150.
Apply appropriate modifiers when necessary:
- 22: Increased procedural services
- 51: Multiple procedures
- 52: Reduced services
- 59: Distinct procedural service
- 78: Return to OR for related procedure
- 79: Unrelated procedure during postop period
- 80/82: Assistant surgeon
- AS: Non-physician assistant
Follow regional and payer-specific billing policies, including Medicare Administrative Contractor (MAC) rules.
Payment is based on Medicare’s Physician Fee Schedule; rates vary by region and payer.

Other relevant CPT codes

58152: Total abdominal hysterectomy with removal of tube(s) and/or ovary(s)
58180: Total abdominal hysterectomy, with removal of tube(s), with or without removal of ovary(s)
58260: Vaginal hysterectomy, for uterus 250 grams or less, with or without removal of tubes/ovaries
58570–58573: Total laparoscopic hysterectomy codes varying by uterus size and removal of tubes/ovaries
58210: Radical abdominal hysterectomy, with bilateral pelvic lymphadenectomy

Frequently asked questions

No. Use 58152 or bill adnexal removal separately with +58720. CPT 58150 includes optional removal of fallopian tubes or ovaries if performed, but separate codes may be used for extensive removal.

No. Lymphadenectomy must be reported with separate codes if performed in addition to the hysterectomy procedure.

Yes, if the surgery involves removal of uterus and cervix. Additional staging or debulking procedures may be coded separately by the provider based on services rendered.