Summary & Overview
CPT 58400: Uterine Suspension for Uterine Prolapse
CPT code 58400 represents a uterine suspension procedure used to correct uterine prolapse by pleating and suturing stretched uterine-support ligaments so the uterus and cervix return to normal position. The code captures a specific pelvic reconstructive surgical technique commonly performed in hospital operating rooms or ambulatory surgical centers and is relevant to gynecologic surgeons, surgical schedulers, and payers given its role in restoring pelvic support and reducing prolapse-related symptoms.
Key payers addressed in the national context include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find clinical context for the procedure, typical sites of service, and the elements that define the billed service. The publication outlines common billing modifiers and highlights areas where claims often require clear operative documentation (for example, ligament types pleated and whether concomitant procedures were performed). The content provides benchmarks and policy-relevant points used by payers and providers for coding consistency, prior authorization considerations, and claims review standards.
This summary is intended for a national audience of clinicians, coding professionals, and payers who need a concise reference to the clinical intent of CPT code 58400, typical care settings, and the administrative elements that commonly accompany billing for uterine suspension procedures.
Billing Code Overview
CPT code 58400 describes a surgical procedure to suspend the uterus by pleating and suturing stretched ligaments (such as the round ligaments or sacrouterine ligaments) so that the uterus and cervix return to their normal positions. The service is performed to correct uterine prolapse, a condition in which the uterus sags or slips from its normal position.
Service type: Pelvic reconstructive surgery for uterine prolapse
Typical site of service: Hospital operating room or ambulatory surgical center
Clinical & Coding Specifications
Clinical Context
A 62-year-old parous woman presents with symptomatic uterine prolapse (vaginal bulge, pelvic pressure, urinary frequency) after years of progressively worsening pelvic organ descent. Conservative measures (pessary, pelvic floor therapy) provided insufficient relief. The pelvic exam confirms a descended uterus with cervix below the hymenal ring consistent with uterine prolapse. The gynecologic surgeon schedules a uterine suspension (ligamentous plication) under general anesthesia in an outpatient ambulatory surgery center. Preoperative evaluation includes pelvic examination, urinalysis, and anesthesia assessment. Intraoperatively the surgeon identifies attenuated round and/or uterosacral ligaments and performs pleating and suture plication to elevate and stabilize the uterus and cervix. Postoperative care includes routine recovery monitoring, multimodal analgesia, voiding trial, discharge with activity restrictions, and a follow-up visit within 2–6 weeks to assess repair integrity and wound healing.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | Use when intraoperative work is substantially greater than typical due to complexity (document rationale). |
23 | Unusual anesthesia |