58571

🧬CPT Code 58571 - Laparoscopic Total Hysterectomy, Uterus ≤250 g, with Removal of Tube(s) and/or Ovary(s)

Quick Reference

wRVU: 15.07 | Global Period: 90 days | Assistant Payable: ✅ Yes | Uterus Weight: ≤250 g | Adnexa Removal: ✅ Included

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📋 Clinical Description

CPT 58571 describes a laparoscopic surgical total hysterectomy — complete removal of the uterus and cervix via a minimally invasive laparoscopic approach — for a uterus weighing 250 grams or less, performed concurrently with removal of one or both fallopian tubes and/or ovaries (unilateral or bilateral salpingectomy, oophorectomy, or salpingo-oophorectomy).

This code sits within the 58570-58573 laparoscopic total hysterectomy family, where code selection hinges on two key clinical variables:

1. Uterine weight — ≤250 g vs. >250 g (documented by intraoperative weight or final pathology report)
2. Adnexal removal — with or without removal of tube(s) and/or ovary(s)

The “total” hysterectomy descriptor specifies that the cervix is removed along with the uterine corpus — distinguishing this from supracervical (subtotal) hysterectomy, in which the cervix is retained. The entirely laparoscopic approach means all dissection, ligation, and specimen extraction are performed through laparoscopic ports without a primary abdominal incision.

The Weight Threshold is Non-Negotiable for Code Selection

Uterine weight must be documented — either by the surgeon’s intraoperative specimen weight or by the final pathology report. The 250 g threshold is not a clinical estimate; it is a CPT code selection criterion. If uterine weight is not recorded, a query to the operating surgeon or pathologist is appropriate before finalizing the code. Defaulting to 58570 or 58571 (≤250 g) when weight is undocumented is a common audit risk.

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🔬 Procedural Technique Overview

Laparoscopic Approach — Standard and Robotic-Assisted

The procedure is performed under general anesthesia in the dorsal lithotomy position. Key steps include:

1. Port placement — typically four trocars: one umbilical (10-12 mm camera port) and 2-3 ancillary ports (5-8 mm) in the lower abdomen; robotic cases use docking-specific port configurations

2. Uterine manipulation — a uterine manipulator (e.g., RUMI, V-Care) is placed vaginally to facilitate exposure and colpotomy

3. Adnexal dissection — bilateral or unilateral round ligament transection, infundibulopelvic (IP) or utero-ovarian (UO) ligament ligation and division; if ovary(s) retained, UO ligament is preserved

4. Bladder dissection — vesicouterine peritoneum incised, bladder reflected inferiorly to expose the cervicovaginal junction

5. Ureteral identification — critical step to prevent ureteral injury; ureters are traced to their entry into the bladder bilaterally

6. Uterine vessel skeletonization and coagulation — uterine arteries and veins are desiccated or stapled at the level of the internal os

7. Colpotomy — circumferential incision of the vaginal cuff at the cervicovaginal junction, guided by the uterine manipulator cup

8. Specimen extraction — uterus and adnexa delivered vaginally or via port site with morcellation if indicated (per ACOG/FDA morcellation guidance in benign disease)

9. Vaginal cuff closure — laparoscopic suturing of the vaginal cuff in a running or interrupted fashion; some surgeons close vaginally

Robotic-Assisted Variant

When performed with robotic assistance (da Vinci or similar platform), the same CPT code family applies. Robotic assistance is not separately reportable as an additional CPT code by the operating surgeon. The facility reports robot-related costs through the HCPCS Level II code S2900 (surgical technique using computer-assisted robotic system) or equivalent facility-specific codes. The surgeon bills 58571 with modifier -22 if operative time and complexity significantly exceed typical expectations due to the robotic platform and clinical complexity.

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⚖️ Code Family - 58570 Through 58573

This is the Most Critical Distinction in This Code Family

All four codes describe laparoscopic total hysterectomy. Selection is determined exclusively by uterine weight and adnexal removal status. Never assume — always verify both variables from the operative report and/or pathology.

Code	Uterine Weight	Adnexa Removed?	wRVU
58570	≤250 g	❌ No	~13.63
58571	≤250 g	✅ Yes	~15.07
58572	>250 g	❌ No	~17.17
58573	>250 g	✅ Yes	~18.41

Clinical Context for Weight Threshold

The average uterus weighs approximately 60-80 g. A uterus enlarged by fibroids can range from 200 g to well over 1,000 g. Most laparoscopic hysterectomies — particularly those performed in straightforward benign disease — fall at ≤250 g, making 58570 and 58571 the most commonly reported of the four. Uteri >250 g are typically associated with significant fibroid burden, adenomyosis, or other pathology enlarging the organ, and often require more complex operative technique.

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✅ Procedure Includes

• Complete laparoscopic removal of the uterus and cervix (total hysterectomy)
• Concurrent laparoscopic removal of one or both fallopian tubes (salpingectomy) and/or one or both ovaries (oophorectomy) or combined salpingo-oophorectomy (BSO or unilateral SO)
• All laparoscopic port placement and closure
• Uterine manipulator placement and use (intraoperative)
• dissection, ligation, and division of uterine supporting ligaments (round, broad, cardinal, uterosacral)
• Uterine vessel ligation/coagulation
• Colpotomy and vaginal cuff closure (laparoscopic or vaginal)
• Intraoperative hemostasis within the operative field
• Specimen removal (vaginal extraction, endobag retrieval, or port-site extraction)
• Routine intraoperative cystoscopy if performed to confirm ureteral integrity — NOTE: some payers bundle routine cystoscopy (52000) into the hysterectomy; confirm per payer LCD

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❌ Excludes / Do Not Report Separately

Code	Description	Relationship to 58571
58570	Laparoscopic total hysterectomy, uterus ≤250 g, WITHOUT adnexa	Mutually exclusive with 58571; adnexa either removed (→ 58571) or not (→ 58570)
58572	Laparoscopic total hysterectomy, uterus >250 g, WITHOUT adnexa	Different weight tier; do not report with 58571
58573	Laparoscopic total hysterectomy, uterus >250 g, WITH adnexa	Different weight tier; do not report with 58571
58661	Laparoscopic removal of adnexal structures (tube/ovary)	Bundled into 58571; adnexal removal is included in the descriptor — never separately report 58661 with 58571
49320	Diagnostic laparoscopy	Bundled; always included in the surgical laparoscopy
58662	Laparoscopic fulguration/excision of pelvic lesions	May be separately reported IF the endometriosis or lesion excision is a separately distinct, documented procedure beyond the scope of the hysterectomy — requires modifier -59 and thorough operative note documentation; subject to CCI review
44970	Laparoscopic appendectomy	May be separately reported when performed for a distinct indication with separate documentation; requires -59 modifier
58100	Endometrial biopsy	Typically a preoperative procedure; do not report on the same date as hysterectomy
57000	Colpotomy	Included in the vaginal cuff work of the total hysterectomy
52000	Cystoscopy	Bundled by many payers when performed as routine confirmation of ureteral integrity during hysterectomy; separately reportable only when therapeutic or diagnostic cystoscopy is performed for a distinct indication

58661 Bundling — Most Common Billing Error

The single most frequently cited unbundling error in gynecologic surgery coding is separately billing 58661 (laparoscopic adnexectomy) alongside 58571. Because 58571’s descriptor explicitly includes removal of tube(s) and/or ovary(s), 58661 is inherently bundled. This triggers a Column 1/Column 2 CCI edit and will be recouped on audit. Never report both.

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🌳 Code Tree - Female Genital System / Laparoscopic Hysterectomy

CPT 58000-58999  Surgery: Female Genital System
│
├── 58150-58294  Open Hysterectomy Procedures
│   ├── 58150  Total abdominal hysterectomy (TAH), with or without tubes/ovaries ≤250 g
│   ├── 58152  TAH with colpo-urethropexy
│   ├── 58180  Supracervical abdominal hysterectomy (SAH)
│   ├── 58200  TAH with partial vaginectomy, pelvic node sampling
│   ├── 58210  Radical abdominal hysterectomy (Wertheim) with pelvic lymphadenectomy
│   └── 58240  Pelvic exenteration for gynecologic malignancy
│
├── 58260-58294  Vaginal Hysterectomy
│   ├── 58260  Vaginal hysterectomy, uterus ≤250 g
│   ├── 58262  Vaginal hysterectomy, uterus ≤250 g, with tube(s)/ovary(s)
│   ├── 58263  Vaginal hysterectomy, ≤250 g, with tube(s)/ovary(s), enterocele repair
│   ├── 58267  Vaginal hysterectomy, ≤250 g, with colporraphy
│   ├── 58270  Vaginal hysterectomy, ≤250 g, with enterocele repair
│   ├── 58290  Vaginal hysterectomy, uterus >250 g
│   ├── 58291  Vaginal hysterectomy, >250 g, with tube(s)/ovary(s)
│   ├── 58292  Vaginal hysterectomy, >250 g, with tube(s)/ovary(s), enterocele repair
│   ├── 58293  Vaginal hysterectomy, >250 g, with colporraphy
│   └── 58294  Vaginal hysterectomy, >250 g, with enterocele repair
│
├── 58541-58544  Laparoscopic Supracervical Hysterectomy (LASH)
│   ├── 58541  LASH, uterus ≤250 g
│   ├── 58542  LASH, uterus ≤250 g, with tube(s)/ovary(s)
│   ├── 58543  LASH, uterus >250 g
│   └── 58544  LASH, uterus >250 g, with tube(s)/ovary(s)
│
├── 58570-58573  Laparoscopic TOTAL Hysterectomy (TLH) ← THIS FAMILY
│   ├── 58570  TLH, uterus ≤250 g
│   ├── ▶▶ 58571 ◀◀  TLH, uterus ≤250 g, WITH tube(s)/ovary(s)  ← YOU ARE HERE
│   ├── 58572  TLH, uterus >250 g
│   └── 58573  TLH, uterus >250 g, WITH tube(s)/ovary(s)
│
├── 58550-58554  Laparoscopic Myomectomy
│   ├── 58552  Laparoscopic myomectomy, with morcellation, intramural fibroids >5 cm
│   └── 58554  Laparoscopic myomectomy with morcellation; any size, if 4 or more fibroids
│
├── 58600-58673  Laparoscopic / Other Adnexal
│   ├── 58661  Laparoscopic removal of adnexal structures (oophorectomy / salpingectomy)
│   ├── 58662  Laparoscopic fulguration/excision of pelvic lesions (endometriosis)
│   └── 58673  Laparoscopic salpingostomy (salpingoneostomy)
│
└── +38900  Intraoperative sentinel lymph node identification (add-on; when applicable for oncologic cases)

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💰 RVU & Reimbursement Profile

Component	Value
Work RVU (wRVU)	~15.07
Global Period	090 (90 days)
Assistant Surgeon (Modifier -80)	✅ Payable
Co-Surgeon (Modifier -62)	✅ Payable when two surgeons each perform a distinct part (e.g., complex oncologic pelvic dissection)
Team Surgery	❌ Not applicable
Bilateral Indicator	3 - Concept does not apply
Modifier 51 Exempt	❌ No (subject to multiple procedure rules when additional procedures reported)
PC/TC Split	❌ Procedure code only
Anesthesia	General; anesthesiologist bills separately (~13 base units)

wRVU Verification

wRVU values are updated annually in the CMS Medicare Physician Fee Schedule (MPFS) Final Rule. The value shown (~15.07) reflects recent MPFS data and should be verified against the current calendar year MPFS Relative Value File available on CMS.gov. Significant RVU revisions occurred in the 2021 E/M restructuring and periodic specialty-specific reviews.

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🏷️ Modifier Reference

Modifier	Name	When to Apply with 58571
-22	Increased Procedural Services	Unusually increased complexity — dense adhesions from prior surgeries/endometriosis, prior pelvic radiation, conversion challenges, significantly prolonged operative time; must document in op note with specific reasons
-51	Multiple Procedures	When additional distinct procedures are performed in the same operative session alongside 58571; subject to 50% reduction on lesser procedures per Medicare
-52	Reduced Services	Procedure partially completed (e.g., converted to open without completing laparoscopic portion; only one adnexa removed when bilateral intended due to adverse intraoperative finding)
-53	Discontinued Procedure	Procedure abandoned after initiation due to patient safety concerns
-59	Distinct Procedural Service	When a separately reportable service (e.g., endometriosis excision, appendectomy) is performed and documentation supports a distinct procedure at a separate site
-80	Assistant Surgeon	Physician assistant surgeon; this code is assistant-payable
-81	Minimum Assistant	When resident or mid-level assists only a minor portion
-62	Co-Surgeons	Two surgeons each performing distinct, required portions (typically in gynecologic oncology cases with complex dissection)
-47	Anesthesia by Surgeon	Rare; documents surgeon administered anesthesia; virtually never applicable in this context
-32	Mandated Services	When procedure is court-ordered or required by payer or governmental authority

Modifier -22 Documentation Requirements

For -22 to be supported and reimbursed, the operative report must explicitly document:

• The specific findings that increased complexity (e.g., “dense adhesions from prior cesarean section obliterating vesicouterine space,” “stage IV endometriosis with complete cul-de-sac obliteration,” “frozen pelvis requiring ureterolysis”)
• Quantified increased operative time vs. typical expectation
• The specific additional work performed beyond the standard procedure Vague statements such as “difficult case” or “complicated anatomy” are insufficient and will not support modifier -22 reimbursement. Expect a 20-30% additional payment when supported — payers will request operative records for review.

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🩺 Common ICD-10-CM Pairings

Leiomyoma / Uterine Fibroids

ICD-10 Code	Description	HCC?	Notes
D25.0	Submucous leiomyoma of uterus	❌ No	Submucosal; most symptomatic fibroid type
D25.1	Intramural leiomyoma of uterus	❌ No	Most common fibroid location overall
D25.2	Subserous leiomyoma of uterus	❌ No	Pedunculated variants common
D25.9	Leiomyoma of uterus, unspecified	❌ No	Use specific subtype when documented

Fibroid Coding Pearl

Code the most specific subtype of leiomyoma documented in the clinical record or operative report. If multiple fibroid types are present (e.g., both intramural and subserous), code each separately. All leiomyoma codes are benign — they carry no HCC weight but are critical for DRG sequencing and medical necessity.

Abnormal Uterine Bleeding (AUB)

ICD-10 Code	Description	HCC?	Notes
N92.0	Excessive and frequent menstruation with regular cycle	❌ No	Menorrhagia with regular cycle (AUB-H per FIGO classification)
N92.1	Excessive and frequent menstruation with irregular cycle	❌ No	Menometrorrhagia
N92.3	Ovulation bleeding	❌ No	Mid-cycle spotting
N92.4	Excessive bleeding in premenopausal period	❌ No	Perimenopausal AUB
N93.0	Postcoital and contact bleeding	❌ No	Rule out cervical pathology
N93.8	Other specified abnormal uterine and vaginal bleeding	❌ No	FIGO AUB categories not elsewhere classified
N93.9	Abnormal uterine and vaginal bleeding, unspecified	❌ No	Use specific code when documented
N85.00	Endometrial hyperplasia, unspecified	❌ No	Often precursor concern driving surgical decision
N85.01	Benign endometrial hyperplasia	❌ No	Without atypia
N85.02	Endometrial intraepithelial neoplasia (EIN)	❌ No	Atypical endometrial hyperplasia; high AH-to-cancer conversion risk

Endometriosis

ICD-10 Code	Description	HCC?	Notes
N80.0	Endometriosis of uterus (adenomyosis)	❌ No	Adenomyosis specifically; often co-coded with uterine enlargement
N80.1	Endometriosis of ovary	❌ No	Endometrioma; often bilateral
N80.2	Endometriosis of fallopian tube	❌ No	Less common site
N80.3	Endometriosis of pelvic peritoneum	❌ No	Most common pelvic implant location
N80.4	Endometriosis of rectovaginal septum and vagina	❌ No	Deep infiltrating endometriosis
N80.5	Endometriosis of intestine	❌ No	Bowel involvement; adds complexity — consider modifier -22
N80.9	Endometriosis, unspecified	❌ No	Use specific site when documented

Adnexal Pathology

ICD-10 Code	Description	HCC?	Notes
N83.20	Unspecified ovarian cysts	❌ No	Functional or simple cyst NOS
N83.201	Unspecified ovarian cyst, right side	❌ No	Use laterality when documented
N83.202	Unspecified ovarian cyst, left side	❌ No
N83.10	Corpus luteum cyst, unspecified side	❌ No	Hemorrhagic corpus luteum
N83.512	Torsion of left ovary and ovarian pedicle	❌ No	Emergency indication; drives urgent/emergent coding
N83.521	Torsion of right fallopian tube	❌ No
Q50.01	Congenital absence of ovary, unilateral	❌ No	Relevant when contralateral oophorectomy planned

Malignant Neoplasms

ICD-10 Code	Description	HCC?	HCC Category (v28)	Notes
C54.1	Malignant neoplasm of endometrium	✅ Yes	Cancer HCC	Most common gynecologic malignancy in the US; SLN mapping (+38900) often added
C54.2	Malignant neoplasm of myometrium	✅ Yes	Cancer HCC	Uterine sarcoma variant
C54.3	Malignant neoplasm of fundus uteri	✅ Yes	Cancer HCC
C55	Malignant neoplasm of uterus, part unspecified	✅ Yes	Cancer HCC	Use specific subsite when available
C56.1	Malignant neoplasm of right ovary	✅ Yes	Cancer HCC	58571 may be used in early-stage ovarian CA; more advanced cases may require 58210
C56.2	Malignant neoplasm of left ovary	✅ Yes	Cancer HCC
C56.3	Malignant neoplasm of bilateral ovaries	✅ Yes	Cancer HCC
C57.00	Malignant neoplasm of unspecified fallopian tube	✅ Yes	Cancer HCC	Primary fallopian tube carcinoma; rare
D39.0	Neoplasm of uncertain behavior of uterus	❌ No	Borderline/uncertain — awaiting definitive histology
D39.10	Neoplasm of uncertain behavior, unspecified ovary	❌ No	Borderline ovarian tumor

Secondary / Metastatic Diagnoses

ICD-10 Code	Description	HCC?	HCC Category (v28)	Notes
C77.5	Secondary malignant neoplasm, intrapelvic lymph nodes	✅ Yes - HCC 17	Metastatic Cancer	Confirmed pelvic nodal metastasis
C79.60	Secondary malignant neoplasm, unspecified ovary	✅ Yes - HCC 17	Metastatic Cancer	Ovarian metastasis from another primary (e.g., Krukenberg tumor from gastric CA)
C78.6	Secondary malignant neoplasm of retroperitoneum and peritoneum	✅ Yes - HCC 17	Metastatic Cancer	Peritoneal carcinomatosis

Other Common Co-Diagnoses

ICD-10 Code	Description	HCC?	Notes
Z30.2	Encounter for sterilization	❌ No	When hysterectomy is performed partly for permanent sterilization intent
N97.9	Female infertility, unspecified	❌ No	When procedure relates to evaluation of infertility-related pathology
Z17.0	Estrogen receptor positive status	❌ No	Important secondary for oncologic cases
Z85.42	Personal history of malignant neoplasm of other female genital organs	❌ No	Prior GYN malignancy history relevant to current surgery
Z84.81	Family history of carrier of genetic disease (e.g., BRCA)	❌ No	Prophylactic/risk-reducing BSO context
Z15.01	Genetic susceptibility to malignant neoplasm of breast (BRCA1)	❌ No	Prophylactic BSO for BRCA1/2 carriers is a primary indication for adnexal removal
Z15.02	Genetic susceptibility to malignant neoplasm of ovary (BRCA2)	❌ No

HCC Mapping Note - v28

All primary uterine and ovarian malignancy codes (C54.x, C55, C56.x) map to a cancer-category HCC under CMS-HCC Model v28, elevating RAF scores significantly in Medicare Advantage populations. Secondary malignancy codes (C77.5, C78.6, C79.60) map to HCC 17 - Metastatic Cancer and Acute Leukemia, which carries one of the highest RAF weights in the model. Accurate capture of confirmed malignant and metastatic diagnoses is critical in oncologic hysterectomy cases for appropriate risk adjustment.

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🏥 MS-DRG Considerations (Inpatient)

Inpatient Facility Reminder

In the DRG-based inpatient setting, CPT 58571 is not used. The ICD-10-PCS equivalent codes are submitted instead. MS-DRG assignment is driven by:

1. Principal Diagnosis (the condition chiefly responsible for admission)
2. ICD-10-PCS procedure codes (which surgical grouping the DRG falls into)
3. CC/MCC status of secondary diagnoses

Non-Malignant Indications (Fibroids, AUB, Endometriosis)

MS-DRG	Title	GMLOS	Key Driver
742	Uterine & Adnexa Procedures for Non-Malignancy with CC/MCC	~2.9 days	CC or MCC secondary diagnosis present
743	Uterine & Adnexa Procedures for Non-Malignancy w/o CC/MCC	~1.7 days	No CC/MCC; clean case

Malignant Indications (Endometrial CA, Ovarian CA)

MS-DRG	Title	GMLOS	Key Driver
734	Pelvic Evisceration, Radical Hysterectomy, Radical Vulvectomy with MCC	~9.2 days	Radical procedures; very high complexity
735	Pelvic Evisceration, Radical Hysterectomy, Radical Vulvectomy with CC	~5.1 days
736	Pelvic Evisceration, Radical Hysterectomy, Radical Vulvectomy w/o CC/MCC	~2.9 days
743	Uterine & Adnexa Procedures for Ovarian or Adnexal Malignancy with MCC	~6.1 days	Ovarian/adnexal CA; MCC secondary (e.g., sepsis, respiratory failure)
744	Uterine & Adnexa Procedures for Ovarian or Adnexal Malignancy with CC	~4.0 days	CC secondary
745	Uterine & Adnexa Procedures for Ovarian or Adnexal Malignancy w/o CC/MCC	~2.5 days	Clean malignancy case
746	Uterine & Adnexa Procedures for Non-Ovarian/Adnexal Malignancy with MCC	~7.4 days	Endometrial CA with major complication
747	Uterine & Adnexa Procedures for Non-Ovarian/Adnexal Malignancy with CC	~4.3 days	Endometrial CA with CC
748	Uterine & Adnexa Procedures for Non-Ovarian/Adnexal Malignancy w/o CC/MCC	~2.6 days	Endometrial CA, uncomplicated

CC/MCC Capture — Gynecologic Oncology Inpatients

Secondary Diagnosis	Code	CC/MCC Status
Severe (protein-calorie) malnutrition	E43	MCC
Moderate malnutrition	E44.0	CC
Anemia in neoplastic disease	D63.0	CC
Postoperative urinary retention	R33.9	CC
Ileus, postoperative	K56.0	CC
Pulmonary embolism (PE)	I26.09	MCC
DVT, lower extremity	I82.401	CC
Wound dehiscence, surgical	T81.31XA	CC
Dehydration	E86.0	CC
Sepsis (postoperative)	A41.9	MCC
Hyponatremia	E87.1	CC

In gynecologic oncology admissions, malnutrition (E43, E44.0) is frequently present but underdocumented. A clinical query to the attending when albumin <3.0, BMI <18.5, or nutritional decline is noted in the record can appropriately elevate DRG tier and is a legitimate and high-yield CDI opportunity.

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🔧 ICD-10-PCS Equivalents (Inpatient Facility Coding)

In the inpatient DRG setting, 58571 maps to a combination of ICD-10-PCS codes that must be reported individually for each distinct body part removed.

PCS Root Operation: Resection (T)

Why Resection (T) and Not Excision (B)?

Resection (T) is the correct root operation when the entire body part is removed — uterus, cervix, ovary, or fallopian tube taken in its entirety. Excision (B) would be used only if a portion of the body part remains (e.g., wedge resection of an ovary). In total hysterectomy with BSO, all body parts are removed entirely — Resection applies to all PCS codes.

Core PCS Codes for 58571 (Laparoscopic Total Hysterectomy with BSO)

PCS Code	Description	Notes
0UT94ZZ	Resection of Uterus, Percutaneous Endoscopic Approach	Always required — total hysterectomy
0UTA4ZZ	Resection of Uterine Supporting Structure (Cervix included in uterus code for total hyst)	Cervix is included within 0UT94ZZ for total hysterectomy per PCS convention
0UT74ZZ	Resection of Right Fallopian Tube, Percutaneous Endoscopic	Right salpingectomy component
0UT84ZZ	Resection of Left Fallopian Tube, Percutaneous Endoscopic	Left salpingectomy component
0UT14ZZ	Resection of Right Ovary, Percutaneous Endoscopic	Right oophorectomy
0UT04ZZ	Resection of Left Ovary, Percutaneous Endoscopic	Left oophorectomy
0UT24ZZ	Resection of Bilateral Ovaries, Percutaneous Endoscopic	Use when both ovaries removed; may replace the two separate ovary codes per facility convention

PCS Coding Convention - Unilateral vs. Bilateral Adnexa

• If both ovaries are removed: code 0UT24ZZ (Bilateral Ovaries) OR code each ovary separately (0UT14ZZ + 0UT04ZZ) — follow your facility’s ICD-10-PCS convention; some facilities prefer the bilateral code, others code each side
• If only one ovary is removed: code the specific side only (0UT14ZZ right or 0UT04ZZ left)
• If both fallopian tubes are removed: code each tube separately (0UT74ZZ + 0UT84ZZ) — there is no bilateral fallopian tube body part value in ICD-10-PCS; tubes must be coded individually
• If only one tube is removed: code the specific side only

PCS Character Analysis - 0UT94ZZ (Uterus Resection, Laparoscopic)

Position	Character	Value	Definition
1	Section	0	Medical and Surgical
2	Body System	U	Female Reproductive System
3	Root Operation	T	Resection (complete removal of body part)
4	Body Part	9	Uterus
5	Approach	4	Percutaneous Endoscopic (laparoscopic)
6	Device	Z	No Device
7	Qualifier	Z	No Qualifier

Robotic Approach PCS Note

Robotic-assisted laparoscopic procedures are coded with approach 4 (Percutaneous Endoscopic) in ICD-10-PCS — there is no distinct approach value for robotic-assisted surgery. The PCS codes are identical whether the laparoscopic procedure is performed with standard instruments or with robotic assistance.

Conversion to Open — Approach Change

If the laparoscopic procedure is converted to open (laparotomy) intraoperatively, the approach character changes from 4 (Percutaneous Endoscopic) to 0 (Open):

PCS Code	Description
0UT90ZZ	Resection of Uterus, Open Approach
0UT10ZZ	Resection of Right Ovary, Open Approach
0UT00ZZ	Resection of Left Ovary, Open Approach

Note

Code the approach that reflects how the majority of the procedure was completed, or per ICD-10-PCS Official Guideline B3.2d, which addresses procedures converted from one approach to another.

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📝 Coding Examples

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Example 1 - Outpatient ASC: Symptomatic Fibroids, Laparoscopic Total Hysterectomy with BSO

Clinical Scenario: A 46-year-old female with symptomatic intramural leiomyomas (D25.1) and menorrhagia (N92.0) undergoes laparoscopic total hysterectomy with bilateral salpingo-oophorectomy at an outpatient ASC. No assistant surgeon. Uterine specimen weight per pathology: 187 g. Operative note documents bilateral adnexal removal. No adhesions or additional procedures. Patient discharged same day.

Field	Code	Rationale
CPT - Primary	58571	TLH ≤250 g (187 g) WITH bilateral adnexal removal
PDx	D25.1	Intramural leiomyoma — primary indication; drives DRG if admitted
SDx	N92.0	Menorrhagia; co-existing symptom driving surgical decision

Note:

Uterine weight 187 g → correctly selects 58571 over 58572/58573. If pathology returned 287 g, 58573 would be the correct code — a 4,000+ wRVU-dollar difference in reimbursement.

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Example 2 - Outpatient Hospital: BRCA2 Carrier, Prophylactic BSO with Concurrent TLH

Clinical Scenario: A 42-year-old female with BRCA2 genetic susceptibility (Z15.02) elects prophylactic bilateral salpingo-oophorectomy. Due to concurrent AUB and endometrial hyperplasia (N85.02 — EIN with atypia), the gynecologist elects to perform laparoscopic total hysterectomy with BSO in the same session. Uterine weight: 72 g. Assistant surgeon scrubbed for the second half of the case.

Field	Code	Rationale
CPT - Primary	58571	TLH ≤250 g (72 g) WITH bilateral adnexal removal
CPT - Assistant	58571-80	Assistant surgeon; this code is assistant-payable
PDx	N85.02	EIN (atypical hyperplasia) — most clinically significant condition driving hysterectomy
SDx	Z15.02	BRCA2 genetic susceptibility — supports adnexal removal medical necessity
SDx	N93.8	AUB, other specified — contributing indication

Payer Note: For BRCA-related prophylactic cases, medical necessity documentation (genetic counseling note, positive genetic test result, NCCN guideline reference) must be included with any prior auth or supporting records submission.

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Example 3 - Inpatient: Endometrial Carcinoma with SLN Mapping and Concurrent Pelvic Washings

Clinical Scenario: A 61-year-old female is admitted for laparoscopic total hysterectomy with BSO for endometrial carcinoma (C54.1) FIGO Stage I. Concurrent procedures: bilateral pelvic SLN mapping with ICG dye (+38900), pelvic washings submitted for cytology (58900 - not separately reported per bundling with hysterectomy). Uterine weight: 210 g. Concurrent diagnoses: moderate malnutrition (E44.0) and mild anemia (D64.9).

ICD-10-PCS (Inpatient Facility):

Code	Description
0UT94ZZ	Resection of Uterus, Percutaneous Endoscopic
0UT74ZZ	Resection of Right Fallopian Tube, Percutaneous Endoscopic
0UT84ZZ	Resection of Left Fallopian Tube, Percutaneous Endoscopic
0UT24ZZ	Resection of Bilateral Ovaries, Percutaneous Endoscopic
07B90ZX	Excision of Pelvic Lymphatic, Open, Diagnostic (right pelvic SLN)

ICD-10-CM Diagnoses:

Sequence	Code	Description	HCC / DRG Role
PDx	C54.1	Malignant neoplasm of endometrium	Drives uterine malignancy DRG
SDx	C56.3	Bilateral ovaries — if ovarian involvement noted	HCC - Cancer
SDx	E44.0	Moderate protein-calorie malnutrition	CC - upgrades DRG
SDx	D63.0	Anemia in neoplastic disease	CC - upgrades DRG
SDx	Z17.0	Estrogen receptor positive (if documented)	Clinical context

MS-DRG Assignment:

Scenario	DRG	GMLOS
With E44.0 + D63.0 (CC)	747 - Uterine & Adnexa Proc for Non-Ovarian Malignancy with CC	~4.3 days
Without CC/MCC	748 - Uterine & Adnexa Proc for Non-Ovarian Malignancy w/o CC/MCC	~2.6 days
If MCC present (e.g., E43 severe malnutrition)	746 - With MCC	~7.4 days

Outpatient/Physician Billing: CPT: 58571 + +38900 (SLN add-on) | Assistant: 58571-80

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Example 4 - Complex Outpatient Case: Stage IV Endometriosis with Ureterolysis, Modifier -22

Clinical Scenario: A 38-year-old female with stage IV endometriosis (N80.3, N80.4), including complete cul-de-sac obliteration and bilateral ureteral involvement, undergoes laparoscopic total hysterectomy with bilateral salpingo-oophorectomy. The operative note documents: 4.5 hours operative time (typical: ~90 minutes), extensive adhesiolysis involving the rectovaginal septum, bilateral ureterolysis to free both ureters from endometriotic nodules, and resection of deep infiltrating endometriotic nodules of the rectovaginal septum. Uterine weight: 94 g.

Field	Code	Rationale
CPT - Primary	58571-22	TLH ≤250 g with bilateral adnexa; 22 for dramatically increased operative complexity — op note must detail all extraordinary findings
CPT - Endometriosis Excision	58662-59	Laparoscopic excision/fulguration of pelvic lesions (deep infiltrating endometriosis, rectovaginal nodule); 59 documents distinct service from hysterectomy
PDx	N80.4	Endometriosis of rectovaginal septum — most severe and clinically dominant site
SDx	N80.3	Endometriosis of pelvic peritoneum
SDx	N80.2	Endometriosis of fallopian tube (if documented)

Modifier -22 Audit Risk

This is one of the highest-audit modifier combinations in gynecologic surgery. Documentation must be airtight — the operative report should include: specific anatomical findings, estimated blood loss, operative time compared to typical, specific additional procedures performed beyond standard hysterectomy, and any intraoperative complications or near-miss events. Without this documentation granularity, the -22 payment will be recouped.

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⚠️ Common Coding Pitfalls

• Uterine weight not documented or verified: The single most impactful error — defaulting to ≤250 g codes without verifying pathology weight. If the uterus weighs 312 g and 58571 is reported instead of 58573, this is a significant underpayment (wRVU difference of ~3.34) and an accuracy error. Always cross-reference the pathology report.

• Separately reporting 58661 with 58571: Adnexal removal is explicitly included in 58571’s descriptor. Reporting 58661 for the salpingectomy or oophorectomy is unbundling and will trigger a CCI Column 1/Column 2 edit denial.

• Confusing total vs. supracervical hysterectomy codes: 58571 = total (cervix removed). If the cervix was retained (LASH — laparoscopic supracervical hysterectomy), the correct family is 58541-58544. Always verify in the operative report whether the cervix was resected or retained.

• Reporting 49320 (diagnostic laparoscopy) with 58571: A surgical laparoscopy always includes the diagnostic component. Never separately report a diagnostic laparoscopy with a surgical laparoscopy of the same region in the same session.

• Omitting modifier -22 on genuinely complex cases: The flip side of the audit risk — failing to capture legitimate complexity (stage IV endometriosis, frozen pelvis, morbid obesity, prior pelvic radiation, multiple prior surgeries) means leaving significant reimbursement on the table. Document the clinical case for modifier -22 when operative complexity is truly extraordinary.

• Incorrect PCS Resection vs. Excision root operation: In ICD-10-PCS, Resection (T) is used when the entire body part is removed. Using Excision (B) for total hysterectomy misrepresents the procedure and may cause incorrect DRG grouping.

• Missing bilateral fallopian tube PCS codes: In ICD-10-PCS, there is no bilateral fallopian tube body part — each tube must be coded separately. Coding only one tube when bilateral salpingectomy was performed results in incomplete procedure capture.

• Not querying for malnutrition in oncologic hysterectomy cases: Moderate malnutrition (E44.0) is a CC that upgrades DRG 748 to 747 in endometrial CA cases. Oncologic patients frequently have nutritional compromise — if lab values (albumin, prealbumin, BMI) suggest it and the physician hasn’t documented it, a CDI query is appropriate and high-yield.

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📎 Sources

^{AMA CPT 2024 Professional Edition} · ^{CMS 2024 Medicare Physician Fee Schedule Final Rule (CMS-1784-F) and MPFS Relative Value File} · ^{CMS-HCC Risk Adjustment Model v28 (2024)} · ^{CMS MS-DRG Grouper v41.1 Definitions Manual} · ^{ICD-10-PCS Official Guidelines for Coding and Reporting FY2024, Sections B3 and B6} · ^{ICD-10-CM Official Guidelines for Coding and Reporting FY2024, Section I.C.2} · ^{CCI Edits Table, CMS Q1 2024} · ^{ACOG Practice Bulletin No. 226: Intraoperative and Postoperative Hemorrhage During Gynecologic Surgery} · ^{NCCN Clinical Practice Guidelines: Uterine Neoplasms v1.2024} · ^{AAPC CPC & CIC Study Curriculum 2024} · ^{SGO Clinical Practice Statement: SLN Mapping in Endometrial Cancer, 2023}