CPT 58410 Uterine Suspension Reimbursement | OpenPayer

Summary & Overview

CPT 58410: Uterine Suspension for Uterine Prolapse

CPT code 58410 represents surgical uterine suspension (pleating and suturing of stretched ligaments, with presacral sympathectomy) performed to correct uterine prolapse. This procedure restores the uterus and cervix to their normal positions by reinforcing the round ligaments, sacrouterine ligaments, or other supportive structures. Nationally, management of pelvic organ prolapse has significant clinical and resource implications given its prevalence among women and the procedural setting required for operative repair.

Key payers in the national context include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise clinical context for CPT code 58410, including typical service type and site of service. The publication also provides payer coverage framing and benchmarking content where available, plus policy and coding guidance trends relevant to pelvic reconstructive surgery billing. The material is intended to support coding accuracy, reimbursement alignment, and administrative planning for hospitals and ambulatory surgical centers.

Data not available in the input: associated taxonomies, ICD-10 diagnoses, related codes, detailed payer-specific coverage rules, and service line classification.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicare58410CPTpelvic-reconstructive-surgeryuterine-prolapsegynecologysurgical-procedureambulatory-surgeryhospital-surgery

Billing Code Overview

CPT code 58410 describes a surgical suspension of the uterus for treatment of uterine prolapse. The procedure involves pleating and suturing stretched ligaments (such as the round ligaments or the sacrouterine ligaments) to restore the uterus and cervix to their normal positions and includes a presacral sympathectomy.

Service type: Pelvic reconstructive surgery for uterine prolapse
Typical site of service: Hospital operating room or ambulatory surgical center

Data not available in the input for associated taxonomies, ICD-10 diagnoses, related codes, and service line.

Clinical & Coding Specifications

Clinical Context

A typical patient is a postmenopausal or multiparous woman presenting with symptomatic uterine prolapse (uterine descent) characterized by pelvic pressure, a vaginal bulge, urinary frequency or urgency, and difficulty with hygiene or sexual activity. Clinical evaluation includes history, pelvic examination (quantification of prolapse), urinalysis, and discussion of conservative measures (pessary, pelvic floor therapy). When conservative care fails or the patient desires definitive surgical correction, a uterine suspension procedure is scheduled.

Preoperative workflow includes informed consent, medical optimization, preoperative labs and anesthesia evaluation. The procedure, coded as 58410, involves pleating and suturing stretched uterine-supporting ligaments (for example, round ligaments or uterosacral ligaments) to suspend and restore the uterus and cervix to normal position; a presacral sympathectomy is included. Typical operative setting is an inpatient or outpatient surgical suite within a hospital or ambulatory surgery center. Postoperative care includes monitoring for bleeding, infection, urinary retention, pain control, activity restrictions, and follow-up pelvic exams to assess anatomic correction and symptom resolution.

Typical patient scenario: A 64-year-old woman with stage II–III uterine prolapse, failed pessary management, and bothersome vaginal bulge elects laparoscopic or open uterine suspension. The surgeon performs ligament pleating and suturing with/without concurrent pelvic procedures, obtains hemostasis, and provides standard postoperative instructions and scheduled follow-up visits.

Coding Specifications

Modifier	Description	When to Use

CPT 58520: Repair of Ruptured or Lacerated Uterus

CPT-58400-UTERINE-SUSPENSION-UTERINE-PROLAPSE

CPT 58400: Uterine Suspension for Uterine Prolapse

CPT-58540-ABDOMINAL-HYSTEROPLASTY-UTERINE-ANOMALY-REPAIR

CPT 58540: Abdominal Hysteroplasty for Uterine Anomaly Repair

Taxonomy Code	Specialty	Notes
207V00000X	Obstetrics & Gynecology	Primary specialty performing uterine suspension procedures.
207VF0000X	Female Pelvic Medicine & Reconstructive Surgery (FPMRS)	Subspecialists managing pelvic organ prolapse and complex reconstructions.
208000000X	General Surgery	May participate in complex pelvic procedures in some settings.
207UH0002X	Gynecology & Obstetrics - Laparoscopic Surgery	Surgeons performing minimally invasive approaches for uterine suspension.
331K00000X	Urogynecology (if separate taxonomy used)	Focused on pelvic floor disorders and prolapse repair.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`N81.1`	Uterovaginal prolapse, midline	Common presentation of uterine prolapse that is an indication for suspension procedures.
`N81.2`	Complete uterovaginal prolapse	Advanced prolapse often requiring surgical correction such as uterine suspension.
`N81.3`	Genital prolapse, unspecified	Used when documentation indicates prolapse without specific compartment detail.
`N99.3`	Intraoperative and immediate postoperative complications of gynecological procedures, not elsewhere classified	Used if complications occur related to the procedure.
`R10.2`	Pelvic and perineal pain	Symptom that may be associated with prolapse and documented preoperatively.
`R32`	Unspecified urinary incontinence	May coexist with uterine prolapse and influence combined surgical planning.
`N81.4`	Vaginal vault prolapse after hysterectomy	Relevant if suspension is directed at correcting vault prolapse in a patient with prior hysterectomy.
`R68.89`	Other general symptoms and signs	Sometimes used for nonspecific symptoms requiring further specification; not a primary diagnosis for surgery.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`57240`	Vaginal suspension procedure, abdominal approach; repair of enterocele and/or enterocele plus vaginal wall defect (colpopexy)	May be performed concurrently when vault support or enterocele repair is required with uterine suspension.
`58260`	Total abdominal hysterectomy, with or without removal of tube(s), with or without removal of ovary(s)	Performed when uterine removal is indicated instead of uterine suspension; may be an alternative in the surgical plan.
`57425`	Colposuspension to correct urinary incontinence (laparoscopic or open)	May be performed concurrently if stress urinary incontinence is addressed during the same operative session.
`49999`	Unlisted procedure, abdomen, peritoneum and omentum	Used rarely for novel or atypical approaches if no specific CPT matches adjunct procedures (payer-dependent).
`58611`	Laparoscopy, surgical; with removal of adnexal structures	Performed concurrently if adnexal surgery (oophorectomy or salpingectomy) is indicated at time of uterine suspension.
`57460`	Laparoscopy, surgical; colpopexy, abdominal approach	Commonly used when uterine suspension is performed via an abdominal/laparoscopic colpopexy technique; may describe similar supportive procedures.

`00`	No modifier (default)	Use when no special circumstances or modifiers apply.
`11`	Office or other outpatient service, normal	Use when this service is the primary, standard procedure without complication; sometimes used by facilities per payer rules.
`22`	Increased procedural services	Use when the work required substantially exceeds typical expectations (document rationale).
`23`	Unusual anesthesia services	Use when general anesthesia is contraindicated and unusual anesthetic management is required.
`50`	Bilateral procedure	Use if the procedure is reported bilaterally when applicable by payer policy (rare for this unilateral uterine suspension).
`51`	Multiple procedures	Use when additional distinct procedures are performed during the same operative session.
`52`	Reduced services	Use when the procedure is partially reduced or not completed as originally planned.
`53`	Discontinued procedure	Use when the procedure is started but terminated due to extenuating circumstances.
`62`	Two surgeons	Use when two surgeons work together as primary surgeons performing distinct portions of the procedure.
`63`	Procedure performed on infants under 4 kg	Not typical for this procedure; listed for completeness when age/weight rules apply (rarely used).
`66`	Surgical team (multiple surgeons)	Use when a surgical team approach is documented and payer accepts team coding.
`78`	Unplanned return to the operating room	Use when the patient requires an immediate postoperative return to OR for a complication related to the original procedure.
`80`	Assistant surgeon	Use when an assistant surgeon participates and payer requires reporting of assistant services.
`81`	Minimum assistant surgeon	Use when a minimal assistant participates and documentation supports this level.
`82`	Assistant surgeon (when qualified resident not available)	Use when an assistant surgeon is needed because a qualified resident is not available.

OpenPayer