Summary & Overview
CPT 58552: Vaginal Hysterectomy With Laparoscopic Assistance
CPT code 58552 describes a vaginal hysterectomy with laparoscopic assistance to transect upper uterine and ovarian attachments for a normal-size uterus (≤250 g). This code captures a common minimally invasive gynecologic procedure that balances the benefits of vaginal removal with laparoscopic visualization and division of adnexal attachments. Nationally, accurate coding of 58552 affects clinical documentation, surgical quality measurement, and payment across major payers.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of the clinical procedure and typical sites of service, comparisons of coverage and coding considerations across those payers, and benchmarks relevant to utilization and site-of-service patterns. The publication also summarizes coding nuances, commonly reported modifiers, and implications for surgical claims processing.
The content aims to provide clinicians, billing professionals, and policy analysts with the clinical context and administrative details needed to match operative documentation to the correct code, understand where the procedure is typically performed, and anticipate payer-related documentation expectations. Data not available in the input is noted where applicable.
Billing Code Overview
CPT code 58552 describes a hysterectomy performed through the vagina with laparoscopic assistance to transect the upper uterine and ovarian attachments. The procedure removes the uterus, cervix, fallopian tubes, and ovaries and is specified for a normal size uterus (weighing 250 g or less).
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Service type: Minimally invasive gynecologic surgery (vaginal hysterectomy with laparoscopic assistance)
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Typical site of service: Hospital inpatient or outpatient surgical center, performed in an operating room or procedure suite under general or regional anesthesia
Clinical & Coding Specifications
Clinical Context
A 46-year-old woman with symptomatic uterine fibroids and heavy menstrual bleeding elects definitive surgical management. Preoperative evaluation in the outpatient gynecology clinic includes pelvic examination, transvaginal ultrasound confirming a normal-size uterus (estimated weight ≤250 g), review of medical history, anesthesia assessment, and informed consent for laparoscopic-assisted vaginal hysterectomy with bilateral salpingo-oophorectomy. On the day of service the patient presents to the hospital or ambulatory surgery center. Under general anesthesia, the surgeon uses a laparoscope to visualize and divide the upper uterine and adnexal attachments and then removes the uterus, cervix, fallopian tubes, and ovaries through the vagina. Estimated blood loss, intraoperative findings, and specimen weight are documented. Postoperative recovery occurs in the PACU with standard monitoring and discharge to home or inpatient admission based on recovery, comorbidities, and payer/stay authorization requirements.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | Use when work or complexity substantially exceeds usual for 58552 and documentation supports additional work. |
23 |