Summary & Overview
CPT 58554: Vaginal Hysterectomy with Laparoscopic Assistance for Large Uterus
CPT code 58554 represents a vaginal hysterectomy with removal of the uterus, cervix, and fallopian tubes for a uterus larger than 250 g, performed with laparoscopic assistance to divide upper uterine and ovarian attachments. This procedure is clinically significant as it addresses symptomatic uterine conditions such as fibroids when uterine size precludes a standard vaginal approach; the laparoscopic assistance enables a minimally invasive route for larger uteri. Nationally, the code matters for surgical practice patterns, site-of-service considerations, and payer coverage policies for gynecologic surgery.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of the clinical context for use of CPT code 58554, common payer considerations, and the types of benchmarks and policy topics typically associated with this service, including utilization patterns, site-of-service implications (hospital OR vs ambulatory surgery center), and documentation elements that support the code’s use. The publication also outlines likely areas for insurer policy variation and coding-related issues relevant to gynecologic surgical services.
Data not available in the input: associated taxonomies, specific ICD-10 diagnoses, payer-specific coverage rules, and related codes.
Billing Code Overview
CPT code 58554 describes a vaginal hysterectomy with removal of the uterus, cervix, and fallopian tubes, performed for a larger-than-normal uterus (greater than 250 g). The procedure uses a laparoscope to divide the upper uterine and ovarian attachments and may include removal of the ovaries. This service is a surgical treatment for conditions such as symptomatic fibroids when the uterus size exceeds typical limits for standard vaginal hysterectomy.
-
Service type: Major gynecologic surgical procedure (hysterectomy performed vaginally with laparoscopic assistance)
-
Typical site of service: Hospital operating room or ambulatory surgery center
Clinical & Coding Specifications
Clinical Context
A 44-year-old parous female presents with a history of heavy, irregular menstrual bleeding, pelvic pressure, and symptomatic enlargement of the uterus due to multiple myomas. Imaging (transvaginal ultrasound and MRI) demonstrates an enlarged fibroid uterus estimated to weigh more than 250 g. After failed medical management and counseling, the patient elects definitive surgical management. The planned approach is a vaginal hysterectomy with laparoscopic assistance to divide the upper uterine and adnexal attachments (laparoscopically assisted vaginal hysterectomy) with removal of the uterus, cervix, and fallopian tubes; ovaries may be preserved or removed based on intraoperative findings and preoperative consent.
Preoperative workflow includes history and physical, informed consent documenting indication and planned approach, pregnancy test if applicable, preoperative labs, and anesthesia evaluation. Intraoperative workflow includes laparoscopic inspection, division of utero-ovarian or infundibulopelvic ligaments as needed, mobilization of the uterus, colpotomy, and vaginal removal of the uterus and cervix. Postoperative workflow includes routine PACU recovery, discharge instructions, and pathology submission. Typical site of service is an outpatient or inpatient operating room in a hospital or ambulatory surgery center depending on comorbidities and complexity.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | Exempt from global period reporting (payer-specific) |