Hysterectomy procedures are becoming more frequent for women. According to a study published in the National Library of Medicine, almost 600,000 women undergo hysterectomy procedures annually in the USA.
Yet, many billers don’t know how to file successful claims for these procedures. CPT code 58571 is among the most used laparoscopic hysterectomy codes. We have noticed considerable confusion surrounding this code, even among experienced billers.
That’s why we have created this guide for you. By the end of this guide, you will know exactly what is required for this code and how to file it properly. So, let’s start.
CPT Code 58571 – Description
CPT code 58571 is defined as
“Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s).”
Let us explain this in simpler terms. 58571 represents a total hysterectomy, which is a surgical procedure. The surgery is performed via a minimally invasive technique, laparoscopy. During the procedure, the surgeon removes the entire uterus (including the cervix) and fallopian tubes. The surgery may also involve the removal of the ovaries. However, it is conditional and varies for every patient. What is important to note here is the weight of the ovaries. For CPT code 58571 to be valid, the weight must be equal to or less than 250 grams.
Please note that the word “Total” in the definition entails the removal of both the uterus and cervix. This minor distinction separates 58571 from other supracervical procedures (58541-58544) in which the cervix remains intact.
To make billing easy for you, let’s briefly go over the surgery process.
The surgeon begins the procedure by making a small incision in the abdomen. A camera (laproscope) and other surgical instruments are inserted through these incisions. The surgeon detaches the uterus and cervix, fallopian tubes, and/or ovaries from surrounding structures. He then removes them either through the abdominal incisions or through the vagina.
That said, total hysterectomy procedures are very similar, with only minor differences. However, these differences warrant the use of an entirely different CPT code. Many billers get confused between them. To clear the confusion, we have mentioned the most important codes below:
- 58570: Total hysterectomy for uterus 250g or less
- 58571: Total hysterectomy with removal of tube(s)/ovary(s), uterus 250g or less
- 58572: Total hysterectomy for uterus over 250g
- 58573: Total hysterectomy with removal of tube(s)/ovary(s), uterus over 250g
Scenarios Where CPT Code 58571 is Applicable
CPT code 58571 is used in many OB-GYN cases. The following are some real-world scenarios where it can be applied:
Fallopian Tube Cancer
Suppose that a woman aged 45-50 years visits her gynecologist. She has abdominal pain, bloating, and abnormal vaginal bleeding. Upon asking, she shares that her family has a history of ovarian cancer. The gynecologist performs some tests and diagnoses fallopian tube cancer that has spread to the uterus.
To treat the patient, the physician suggests a surgical approach. So, a laparoscopic total hysterectomy with removal of the fallopian tubes and ovaries is performed for treatment. In this case, the surgery can be billed via CPT code 58571.
Prolapsed Uterus
To make things even clearer, let’s consider another scenario. Imagine that a patient with pelvic pressure, urinary incontinence, and a sensation of vaginal bulging visits the outpatient clinic. The patient is between 50 and 60 years of age and has also had multiple vaginal deliveries. After assessment, the physician confirms a prolapsed uterus. It is a condition in which the uterus descends into the vaginal canal due to weak pelvic support.
Medications will not work here, and the most effective treatment option is to remove the uterus. So, a laparoscopic total hysterectomy with removal of the fallopian tubes is performed to alleviate symptoms. The surgery can be billed with CPT code 58571.
Applicable Modifiers for CPT Code 58571
The following are some modifiers that you can use to describe the circumstances in which the surgery was performed:
| Modifier | What It Means | Description |
|---|---|---|
| 22 | Increased Procedural Services | This modifier indicates that the work done to provide a service was much greater than typically required. |
| 51 | Multiple Procedures | Used when multiple procedures are performed during the same operative session. |
| 53 | Discontinued Procedure | It is used when a procedure is started but discontinued due to extenuating circumstances. |
| 59 | Distinct Procedural Service | Identifies distinct procedures or services that are not usually reported together but are appropriate under certain circumstances. |
| 62 | Different Speciality Surgeons | Used when two surgeons of different specialties work together as primary surgeons. |
| 80 | Assistant surgeon | Indicates that another physician assisted during the procedure. |
CPT Code 58571 – Billing & Reimbursement Guidelines
Whether or not you receive the reimbursement and the expected amount depends on how efficiently you process your claims. The following are some guidelines and vital points that you should consider when filing claims for CPT code 58571:
Medicare Reimbursement
According to the 2025 Physician Fee Schedule, Medicare’s national reimbursement rate for CPT code 58571 is $885.65 (facility settings). However, this rate varies significantly for different MAC localities.
You can check the exact reimbursement rate for your MAC locality via the PFS Lookup Tool.
Documentation Requirements
Documentation for total hysterectomies must be comprehensive. Without proper documentation, your claims will be rejected. The following are some essential records to include in your 58571 claim documentation:
- History and physical exam notes detailing the patient’s symptoms, diagnosis, and conservative treatments attempted.
- Must clearly describe the laparoscopic approach, including detachment of the uterine cervix and body via laparoscope.
- Document the uterus weight as 250 grams or less.
- Include details on any additional steps, such as the use of robotics.
- Note any complications, estimated blood loss, and postoperative status.
- Provide evidence of any pathological findings (e.g., tumors, fibroids, or other abnormalities) that support medical necessity (if applicable).
- Reports of relevant diagnostic evaluations, including laboratory tests, pathology reports, and imaging, such as MRI or CT scans.
Bundled Services
Several sub-procedures are already included in CPT code 58571. They should not be billed separately. Some of these bundled procedures and services are:
- Diagnostic laparoscopy
- Routine lysis of adhesions (extensive lysis might warrant separate coding)
- Abdominal exploration
- Obtaining hemostasis
Some Limitations
Please note that CPT code 58571 cannot be used to bill elective sterilization hysterectomies, tubal ligation, vasectomy, or any other reason that is not an approved medical necessity. Code 58571 cannot be used even if a physician thinks that any future pregnancy can be harmful.
The same goes for gender change surgeries. However, 58571 can be reimbursed for sterilization and gender change if it is a part of treating an illness or supported by a valid and provable medical necessity.
Wrapping Up
Let’s wrap up this guide. CPT code 58571 indicates a total hysterectomy surgery that is performed via laparoscopy. For proper reimbursement, you must provide comprehensive documentation and append the correct modifiers (when needed).
By following the guidelines in this blog, healthcare providers and billers can successfully file claims with CPT 58571 and reduce the denial rate. However, if billing is not your strong suit, you can always get help from our billing consultants. We offer specialized OBGYN billing services at affordable rates.
