Summary & Overview
CPT 58541: Laparoscopic Subtotal Hysterectomy, Uterus Removed; Cervix Preserved
CPT code 58541 represents a laparoscopic subtotal (supracervical) hysterectomy where the uterus is removed through a minimally invasive approach while the cervix and adnexa (fallopian tubes and ovaries) are left intact; the uterus is specified as normal in size (≤ 250 g). This code captures a commonly performed gynecologic surgical option and matters nationally because it affects surgical scheduling, resource use in ambulatory surgery centers and hospital outpatient departments, and payer policy for minimally invasive versus open hysterectomy approaches.
Key payers considered include Aetna, Blue Cross Blue Shield, Cigna, UnitedHealthcare, and Medicare. Readers will find a concise explanation of the code’s clinical intent and typical sites of service, how it maps to procedural service lines, and what components are explicitly described (uterus removed laparoscopically; cervix and adnexa preserved; uterus ≤ 250 g). The publication provides benchmarks and utilization context where available, notes applicable coding considerations, and summarizes policy implications relevant to coverage and site-of-service determination. Data not available in the input for ICD-10 diagnoses, associated taxonomies, and payer-specific reimbursement details are noted as unavailable.
Billing Code Overview
CPT code 58541 describes a laparoscopic subtotal hysterectomy in which the uterus is removed but the cervix is left in place. The description specifies the uterus is normal in size (≤ 250 g) and the fallopian tubes and ovaries are preserved.
Service Type: Surgical — Gynecologic procedure (laparoscopic subtotal hysterectomy)
Typical Site of Service: Hospital outpatient department or ambulatory surgery center, reflecting a minimally invasive abdominal surgical approach performed under anesthesia.
Clinical & Coding Specifications
Clinical Context
A 46-year-old woman with symptomatic uterine fibroids and heavy menstrual bleeding elects for minimally invasive removal of the uterus while preserving the cervix and adnexa. She has completed childbearing and has a uterus of normal size (estimated ≤250 g). Preoperative evaluation includes history and physical, pelvic ultrasound confirming uterine size and fibroid location, routine labs, and anesthesia assessment. The procedure — robotic-assisted or conventional laparoscopic supracervical hysterectomy (58541) — is performed in an outpatient ambulatory surgery center or hospital same-day surgery unit under general anesthesia. Intraoperative steps include trocar placement, laparoscopic visualization, division of the uterine corpus from the cervix, hemostasis, specimen extraction (morcellation if necessary per facility policy), and inspection of fallopian tubes and ovaries, which are preserved. Postoperative workflow includes PACU recovery, discharge instructions for activity restrictions and wound care, and a postoperative clinic visit within 1–2 weeks to assess recovery and remove sutures if needed.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | Use when work, time, and effort substantially exceed typical for 58541. Documentation must justify increased complexity. |