Medical Coding for Hysterectomy Procedures: A Comprehensive Guide

Overview of Hysterectomy

• • Hysterectomy is the second most common surgical procedure for women in the U.S., following cesarean sections, with approximately 600,000 performed annually.
  • Medical coders must understand the reasons for hysterectomy and the appropriate coding to ensure accuracy.

Reasons for Hysterectomy

• • Common indications include:
    • Endometriosis or uterine fibroids causing pain or bleeding
    • Uterine prolapse (sliding of the uterus into the vaginal canal)
    • Cancers of the uterus, ovaries, or cervix
    • Sterilization (inability to become pregnant)
    • Gender affirmation surgery

Common Additional Procedures

• • Hysterectomy may be performed with additional surgeries, such as:
    • Salpingectomy (removal of fallopian tubes)
    • Oophorectomy (removal of ovaries)
    • Vaginectomy (removal of all/part of the vagina)
    • Trachelectomy (removal of all/part of the cervix)
    • Lymphadenectomy (removal of lymph nodes)
    • Enterocele repair (repair of vaginal prolapse)

Key Factors for Accurate Coding

• • Surgical Approach: Determine whether the procedure is:
    • Laparoscopic
    • Vaginal
    • Abdominal
  • Extent of the Procedure: Specify the type of hysterectomy:
    • Total (entire uterus and cervix removed)
    • Subtotal/Supracervical (upper portion of the uterus removed, cervix left intact)
    • Radical (uterus, cervix, adjacent tissues, and upper vagina removed, often for cancer)

CPT Code Categories for Hysterectomy

• • Laparoscopic Hysterectomy:
    • Laparoscopic Supracervical (58541-58544)
  •  58541 Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less;
  •  58542 with removal of tube(s) and/or ovary(s)
  • 58543 Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g
  • 58544 with removal of tube(s) and/or ovary(s) 
    • Laparoscopic Assisted Vaginal Hysterectomy (58550-58554)
  • 58550 Laparoscopy surgical, with vaginal hysterectomy, for uterus 250 g or less;
  • 58552 with removal of tube(s) and/or ovary(s)
  • 58553 Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g;
  • 58554 with removal of tube(s) and/or ovary(s) 
    • Total Laparoscopic Hysterectomy (58570-58573)
  •  58570 Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less;
  • 58571 with removal of tube(s) and/or ovary(s)
  • 58572 Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g;
  • 58573 with removal of tube(s) and/or ovary(s) 
    • Laparoscopic Radical Hysterectomy (58548, 58575)
  • 58548 Laparoscopy, surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with removal of tube(s) and ovary(s), if performed
  • 58575 Laparoscopy, surgical, total hysterectomy for resection of malignancy (tumor debulking), with omentectomy including salpingo-oophorectomy, unilateral or bilateral, when performed
  • Abdominal Hysterectomy:
    • Total Abdominal Hysterectomy (58150-58240)
  • 58150 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s);
  • 58152 with colpo-urethrocystopexy (eg, Marshall-Marchetti-Krantz, Burch)
  • 58180 Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s)
  • 58200 Total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node sampling, with or without removal of tube(s), with or without removal of ovary(s)
  • 58210 Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with or without removal of tube(s), with or without removal of ovary(s)
  • 58240 Pelvic exenteration for gynecologic malignancy, with total abdominal hysterectomy or cervicectomy, with or without removal of tube(s), with or without removal of ovary(s), with removal of bladder and ureteral transplantations, and/or abdominoperineal resection of rectum and colon and colostomy, or any combination thereof
  • Vaginal Hysterectomy:
    • Vaginal Hysterectomy (58260-58294)
    • Vaginal Radical Hysterectomy (58285)
    • Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) (58260-58294)

Important Considerations in Coding

• • Uterus Weight: Some CPT® codes depend on the weight of the uterus. If not documented in the operative report, the weight can be taken from the pathology report, but it is preferred to use the operative report for accuracy.
  • Additional Procedures: Check for additional services performed during the hysterectomy, such as removal of fallopian tubes or ovaries, or enterocele repair. Ensure proper coding for any services that are separately reportable.

Innovations in Hysterectomy

• • vNOTES (Vaginal Natural Orifice Transluminal Endoscopic Surgery): A newer technique combining laparoscopic and vaginal approaches.
    • This procedure uses a laparoscopic device inserted via vaginal incisions, but the hysterectomy is still performed vaginally.
    • The CPT® codes for vaginal hysterectomy (58260-58294) should be used for vNOTES.

Identifying Laparoscopic Procedures

• • Clues in the operative notes to identify laparoscopic procedures:
    • Use of laparoscopic or robotic supplies (e.g., Veress needle, trocar, da Vinci® system)
    • Multiple small incisions vs. a single large incision
    • Insufflation and desufflation of the abdomen
  • If a laparoscopic procedure is converted to an open procedure, the open procedure should be coded.

Case Example: Conversion to Open Surgery

• • A patient undergoing a robotic-assisted total laparoscopic hysterectomy with bilateral salpingectomy had a large uterus (874 grams). Due to size, the procedure was converted to a mini laparotomy for specimen removal.
  • Correct code: 58150 Total abdominal hysterectomy, as the surgery was converted to open.
• Hysterectomy Post-Delivery
  • Following Cesarean Delivery:
    • Use CPT® +59525 for subtotal or total hysterectomy if performed through the same incision as a cesarean.
    • Use CPT® +58611 for fallopian tube ligation or transection performed at the same time.
  • Following Vaginal Delivery:
    • Use the appropriate hysterectomy code (e.g., 58150) depending on the procedure’s approach and extent.

Coding for Trachelectomy

• • Open Trachelectomy: CPT® 57530 (amputation of the cervix).
  • Radical Trachelectomy: CPT® 57531 (with pelvic lymphadenectomy).
  • Laparoscopic Trachelectomy: No specific CPT® code, use:
    • 58578 Unlisted laparoscopic procedure, uterus, or
    • 58661 Laparoscopy with adnexal removal, adding modifier 22 if additional work is performed.

Final Notes

• • Always consult the operative report for details on the surgical approach and any additional procedures.
  • Clarify any missing documentation, such as the uterus weight, with the provider to ensure correct coding.