Summary & Overview
CPT 58545: Laparoscopic Myomectomy, 1–4 Fibroids (≤250 g)
CPT code 58545 designates a laparoscopic myomectomy for excision of one to four uterine fibroids with a combined weight of 250 grams or less. This code captures a common minimally invasive gynecologic procedure that preserves the uterus while addressing symptomatic fibroids; it is relevant nationally due to the prevalence of fibroid-related morbidity among reproductive-age people and implications for surgical access and site-of-service selection. Key payers included in the analysis are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise clinical context for the procedure, expected sites of service, and typical service descriptors. The publication summarizes payer coverage patterns, common billing modifiers, and related policy or reimbursement considerations where available. It also outlines benchmarks and utilization context relevant for surgical departments, coding professionals, and payers managing benefits for gynecologic surgery. Data not available in the input is noted where specific payer policies, ICD-10 diagnosis pairings, or associated taxonomies are absent.
Billing Code Overview
CPT code 58545 describes a laparoscopic myomectomy in which the provider excises fibroid tumors of the uterus. The procedure includes removal of a total of one to four intramural or submucosal fibroids with a combined weight of 250 grams or less, and may include simultaneous removal of tumors on the uterine surface.
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Service type: Minimally invasive surgical excision of uterine fibroids (laparoscopic myomectomy)
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Typical site of service: Hospital outpatient department or ambulatory surgery center where laparoscopic gynecologic procedures are performed.
Clinical & Coding Specifications
Clinical Context
A typical patient is a premenopausal woman presenting with symptomatic uterine leiomyomas (fibroids) causing heavy menstrual bleeding, pelvic pain, or pressure symptoms and refractory to medical therapy. After evaluation with history, pelvic exam, and pelvic ultrasound (or MRI if indicated), the gynecologic surgeon schedules a minimally invasive operative hysteroscopy/laparoscopy for myomectomy. The procedure 58545 is performed laparoscopically to excise one to four intramural or subserosal fibroids weighing 250 g or less in total. The workflow includes preoperative assessment and anesthesia evaluation, placement of laparoscopic ports, visualization of the uterus, enucleation of fibroids with electrosurgical or energy devices, retrieval of specimens (via endobag or morcellation as appropriate and permitted), hemostasis, irrigation, and closure. Postoperative care involves recovery from anesthesia, pain control, discharge instructions or brief inpatient observation if indicated, and pathology submission of excised tissue. Typical site of service is an ambulatory surgery center or hospital outpatient surgical suite. The service type is an operative gynecologic laparoscopic myomectomy under general anesthesia, often billed with appropriate surgical and facility modifiers and correlated with diagnostic codes for leiomyoma or related symptoms.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
51 | Multiple procedures |