Summary & Overview
CPT 58267: Vaginal Hysterectomy with Urethral Suspension
CPT code 58267 represents a vaginal hysterectomy removing the uterus and cervix only, performed through a transvaginal approach with concomitant urethral suspension for stress urinary incontinence. This code applies when the uterus is normal in size (250 g or less) and an endoscope may be used during the operation. Nationally, this code is important for categorizing surgical gynecologic care, aligning clinical documentation with procedural intent, and informing coverage and payment policies for combined hysterectomy and incontinence procedures.
Key payers in the coverage landscape include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise reference to the clinical scenario captured by the code, the typical sites where the service is delivered, and the common procedural context for billing this code. The publication includes benchmarks and policy context relevant to billing and coding consistency, payer coverage patterns, and documentation elements required to support medical necessity. It also highlights coding relationships and common modifier usage where applicable. Data not available in the input is noted where appropriate, and the material is presented for a national audience to support revenue cycle, compliance, and clinical documentation teams.
Billing Code Overview
CPT code 58267 describes a vaginal hysterectomy with removal of the uterus and cervix only, performed through a vaginal approach. The procedure includes suspension of the urethra to address stress urinary incontinence when performed during the same operative session. The description specifies a normal-sized uterus (250 g or less) and permits use of an endoscope during the procedure.
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Service type: Surgical gynecologic procedure
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Typical site of service: Hospital operating room or ambulatory surgery center; performed via a vaginal (transvaginal) approach.
Clinical & Coding Specifications
Clinical Context
A 48-year-old woman with symptomatic uterovaginal prolapse and long-standing stress urinary incontinence presents for definitive surgical management. She has completed childbearing, has a normal-sized uterus estimated ≤250 g on imaging and exam, and desires removal of the uterus and cervix. Preoperative evaluation includes pelvic examination, urinalysis, basic labs, and anesthesia assessment. Under general or regional anesthesia in an operating room at an ambulatory surgery center or hospital outpatient department, the surgeon performs a vaginal hysterectomy with concomitant urethral suspension to correct stress urinary incontinence. An endoscope may be used intraoperatively for visualization or to assist in hemostasis. Postoperative care includes routine recovery in PACU, short observation for urinary retention or bleeding, and discharge with short-term activity restrictions and follow-up for wound and urinary function assessment.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | No modifier (standard) | Use when no specific modifier applies and service is reported as primary. |
22 | Increased procedural services | Use when work or complexity substantially exceeds usual for a vaginal hysterectomy with urethral suspension. |