CPT Code 58571: Laparoscopic Hysterectomy (Total), Uterus ≤250g, Including Removal of Tubes/Ovaries

What is CPT code 58571: Laparoscopic hysterectomy?

The 58571 CPT code refers to laparoscopic surgery for performing a total hysterectomy for a uterus weighing 250 g or less, including the removal of tubes (fallopian tubes) and/or ovary(ies). This surgical procedure utilizes a laparoscopic approach, where the surgeon uses small incisions in the abdomen to detach and remove the uterus and surrounding structures. This method offers the benefits of minimally invasive surgery, such as faster recovery, fewer complications, and less postoperative pain compared to traditional open hysterectomy techniques.

The total laparoscopic hysterectomy involves the complete removal of the uterus and cervix. In the case of CPT 58571, the procedure specifically includes the removal of one or both fallopian tubes and/or ovaries. This code is part of a group that distinguishes procedures based on uterus size, whether adnexal structures are removed, and the surgical approach taken.

Choosing this laparoscopic surgical procedure is often required when the patient has conditions such as fibroids, endometriosis, abnormal bleeding, or prophylactic removal due to cancer risk. Accurate code selection ensures proper reporting and appropriate reimbursement for the services performed. Understanding how to describe and bill this procedure properly is essential for the physician and medical billing staff.

CPT code 58571 documentation requirements

When billing the 58571 CPT code, thorough documentation is typically required to support accurate coding, prove medical necessity, and ensure successful reimbursement. Proper documentation also helps distinguish this surgical procedure from other CPT codes used for hysterectomy, such as vaginal hysterectomy or supracervical hysterectomy.

Key documentation requirements for CPT 58571 include:

• Uterus size: Document that the uterus weighs 250 g or less (≤250 grams).
• Type of procedure: Specify that a total laparoscopic hysterectomy was performed, not a supracervical or vaginal hysterectomy.
• Removal of tubes and/or ovaries: State whether one or both fallopian tubes and/or ovaries were removed during the surgical session.
• Laparoscopic approach: Describe that the surgery was performed using a laparoscopic approach with small abdominal incisions.
• Route of tissue removal: Indicate whether the tissue was removed through the abdomen or vaginally.
• Medical necessity: Include supporting details such as the diagnosis (e.g., fibroids, endometriosis, pelvic pain, cancer risk reduction).
• Differentiation from other codes: Ensure the operative report explains why this code was selected instead of other hysterectomy CPT codes (e.g., supracervical laparoscopic hysterectomy or laparoscopy-assisted vaginal hysterectomy).

Careful documentation supports billing accuracy and reduces the likelihood of denials. It also helps clarify that the procedure meets payer guidelines and meets medical necessity standards for the services rendered.

CPT code 58571 billing guidelines

Accurate billing for the 58571 CPT code ensures that healthcare providers receive appropriate reimbursement for the laparoscopic surgical procedure. Since hysterectomy codes are highly specific based on factors like uterus size, surgical approach, and whether adnexal structures were removed, following the correct guidelines is critical.

• Use CPT Code 58571 only for total laparoscopic hysterectomy for a uterus weighing 250 g or less with the removal of tube(s) and/or ovaries.
• Do not bill CPT 58571 with other hysterectomy CPT codes such as vaginal hysterectomy (58550–58554) or supracervical laparoscopic hysterectomy (58541–58544).
• Verify payer policies since many insurance plans typically require prior authorization for this surgical procedure.
• Check for bundling rules. Procedures like cystoscopy or lysis of adhesions performed during the same session may not be separately reimbursed unless justified.
• Include proper diagnosis codes to support medical necessity, including indications like fibroids, abnormal bleeding, endometriosis, or preventative cancer surgery.
• Confirm that documentation aligns with the operative report and coding details to prevent audit issues.

By following these billing guidelines, physicians and teams can avoid claim denials and ensure accurate service reimbursement. Proper coding also promotes clear communication with payers about the scope of the surgical procedure.

Other related codes

The choice of hysterectomy CPT codes depends on several important factors, including uterus size, whether the removal of tubes and/or ovaries was performed, and the surgical approach (laparoscopic, abdominal, or vaginal). Selecting the correct code helps ensure compliance with payer rules and reduces errors in claims processing.

Here’s a summary of related specific codes:

• 58570 – Total laparoscopic hysterectomy, uterus ≤250 g
• 58572 – Total laparoscopic hysterectomy, uterus >250 g
• 58573 – Total laparoscopic hysterectomy with removal of tubes/ovaries, uterus >250 g
• 58541 – Supracervical laparoscopic hysterectomy without removal of tubes/ovaries, uterus ≤250 g
• 58542 – Supracervical laparoscopic hysterectomy with removal of tubes/ovaries, uterus ≤250 g
• 58550 – Laparoscopy with vaginal hysterectomy without removal of tubes/ovaries, uterus ≤250 g
• 58552 – Laparoscopy with vaginal hysterectomy with removal of tubes/ovaries, uterus ≤250 g,

This breakdown helps clarify the selection of specific codes based on surgical details, approach, and uterus size.