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The procedure described by CPT® Code 58546 involves a laparoscopic surgical technique known as myomectomy, specifically targeting the excision of five or more intramural myomas or intramural myomas that collectively weigh more than 250 grams. Myomas, commonly referred to as uterine fibroids, are benign tumors that develop from the muscle tissue of the uterus, known as the myometrium. These fibroids can manifest in various forms, including submucous, intramural, subserous, or pedunculated types. Submucous fibroids extend into the uterine cavity and are typically addressed through hysteroscopy, while intramural fibroids are embedded within the uterine muscle itself. Subserous fibroids are located on the outer surface of the uterus and may be attached by a thin stalk, known as pedunculation. During the laparoscopic myomectomy, the surgeon makes a small incision below the umbilicus to insert a trocar, which allows for the introduction of a laparoscope—a specialized instrument that provides visual access to the uterus. The surgeon inspects the uterus to locate the fibroids and then creates two or three additional incisions in the lower abdomen to facilitate the insertion of surgical instruments. For surface fibroids, an incision is made directly over the fibroid to detach it from the uterine wall. In the case of intramural fibroids, the surgeon incises the uterus down to the fibroid level, carefully peeling the tumor away from the myometrium. Depending on the fibroid's size, it may be removed intact or morcellated into smaller pieces for extraction. Throughout the procedure, any bleeding is managed using electrocautery, and the uterus is subsequently repaired in layers with sutures. This procedure is indicated for patients with multiple or significantly large fibroids, providing a minimally invasive option for symptom relief and preservation of uterine function.
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The laparoscopic myomectomy procedure described by CPT® Code 58546 is indicated for the following conditions:
The laparoscopic myomectomy procedure involves several key steps to ensure the effective removal of the fibroids:
Post-procedure care following a laparoscopic myomectomy includes monitoring for any complications, managing pain, and ensuring proper recovery. Patients are typically advised to rest and may be given specific instructions regarding activity limitations. Follow-up appointments are essential to assess healing and address any concerns. The expected recovery time can vary, but many patients can return to normal activities within a few weeks, depending on individual circumstances and the extent of the surgery performed.
| Short Descr | LAPARO-MYOMECTOMY COMPLEX | Medium Descr | LAPS MYOMECTOMY EXC 5/> MYOMAS >250 GRAMS | Long Descr | Laparoscopy, surgical, myomectomy, excision; 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 g | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 2 - Co-surgeons permitted and no documentation required if the two- specialty requirement is met. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 125 - Other excision of cervix and uterus |
This is a primary code that can be used with these additional add-on codes.
| 49327 | Addon Code MPFS Status: Active Code APC N ASC N1 Laparoscopy, surgical; with placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), intra-abdominal, intrapelvic, and/or retroperitoneum, including imaging guidance, if performed, single or multiple (List separately in addition to code for primary procedure) |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 62 | Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate. | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician |
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| 2011-01-01 | Changed | Short description changed. |
| 2007-01-01 | Changed | Code description changed. |
| 2003-01-01 | Added | First appearance in code book in 2003. |
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