Summary & Overview
CPT 58262: Vaginal Hysterectomy with Bilateral Salpingo-Oophorectomy
CPT code 58262 represents a total vaginal hysterectomy with bilateral salpingo-oophorectomy for a uterus of normal size (≤250 g). This gynecologic surgical procedure is a common operative option for conditions such as symptomatic fibroids, benign uterine disease, pelvic pain, or gynecologic malignancy management when appropriate. Nationally, coding clarity for this procedure affects surgical case classification, facility utilization, and bundled payment calculations across public and private payers.
Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise clinical description, typical sites of service, common billing considerations, and the types of benchmarks and policy elements that influence reimbursement and utilization. The publication outlines service-level context for coding and claims submission, highlights the significance of accurate documentation when the uterus is within the normal weight threshold, and summarizes which stakeholders commonly cover this service.
The content is intended to provide operational and coding teams, revenue cycle staff, and policy analysts with a clear reference for CPT code 58262, including what the code represents, where it is typically performed, and which national payers are commonly involved. Data not available in the input is noted where applicable.
Billing Code Overview
CPT code 58262 describes a vaginal hysterectomy with removal of the uterus, cervix, fallopian tubes, and ovaries when the uterus is normal in size (weighing 250 g or less). The procedure is performed via a vaginal approach and involves complete removal of the reproductive organs stated in the description.
Service Type: Surgical — Gynecologic Procedure (Vaginal Hysterectomy)
Typical Site of Service: Inpatient hospital or ambulatory surgical center with surgical suite, depending on clinical indication and facility capability.
Clinical & Coding Specifications
Clinical Context
A 48-year-old female with symptomatic uterine fibroids and heavy menstrual bleeding elects to undergo a total vaginal hysterectomy with bilateral salpingo-oophorectomy. The patient presents to the hospital preoperatively for surgical clearance, anesthesia evaluation, and informed consent. On the day of surgery she is admitted to an ambulatory surgery unit or hospital operating room, receives regional or general anesthesia, and undergoes removal of the uterus, cervix, both fallopian tubes, and both ovaries via a vaginal approach. Intraoperative steps include vaginal cuff closure and hemostasis; estimated blood loss and specimen weight are documented (uterus ≤250 g). Postoperative recovery occurs in the PACU with discharge to inpatient ward or home depending on anesthesia and facility. Typical documentation includes primary indication, preoperative diagnoses, procedure note with surgical findings and specimen weight, anesthesia record, and postoperative orders.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | For unusually complex vaginal hysterectomy requiring substantially greater work |
23 | Unusual anesthesia | When general anesthesia is medically necessary for a procedure normally done with local/regional
51 | Multiple procedures | When additional unrelated surgical procedures are performed in same operative session