58571 CPT Code: Description, Billing Guidelines, Modifiers & Documentation 

Accurate reporting of the 58571 CPT code is essential for proper reimbursement, claim approval, and coding compliance. Understanding its procedural requirements helps providers, coders, and billers minimize errors while improving revenue cycle performance and accuracy.

The 58571 CPT code description applies to a total laparoscopic hysterectomy for a uterus weighing 250 grams or less, including removal of the fallopian tubes, with or without the ovaries. Proper documentation supports accurate code selection and reimbursement.

This guide explains the 58571 CPT code in detail, covering its description, coding requirements, billing guidelines, reimbursement considerations, and common mistakes to help healthcare practices submit accurate claims.

In This Guide, You’ll Learn:

• What is the 58571 CPT code?
• 58571 CPT code description explained
• When to use CPT code 58571
• CPT 58571 vs. related hysterectomy CPT codes
• Documentation requirements for accurate coding
• Modifier guidelines for CPT code 58571
• Common ICD-10 diagnosis codes
• Billing guidelines and reimbursement considerations
• Common claim denials and how to avoid them

What Is the 58571 CPT Code?

The 58571 CPT code is used to report a total laparoscopic hysterectomy (TLH) performed for a uterus weighing 250 grams or less, including the removal of the fallopian tubes, with or without the ovaries. It is a surgical procedure commonly performed to treat benign gynecological conditions such as uterine fibroids, abnormal uterine bleeding, endometriosis, and adenomyosis when conservative treatment options have not been successful.

Unlike an open hysterectomy, this procedure is completed using a laparoscope and specialized surgical instruments inserted through small abdominal incisions. The uterus and cervix are detached laparoscopically, and the specimen is removed through the vagina or, when clinically appropriate, through the laparoscopic ports. This minimally invasive approach typically results in less postoperative pain, reduced blood loss, shorter hospital stays, and faster patient recovery.

Official 58571 CPT Code Description

CPT Code 58571: Laparoscopy, surgical, with total hysterectomy, for uterus 250 grams or less, with removal of tube(s) and/or ovary(s).

To better understand the code, here’s what each component means:

• Laparoscopy, surgical: The procedure is performed using a minimally invasive laparoscopic technique.
• Total hysterectomy: Both the uterus and cervix are completely removed.
• Uterus 250 grams or less: The uterine weight, confirmed by the pathology report, must not exceed 250 grams.
• With removal of tube(s) and/or ovary(s): The procedure includes the removal of one or both fallopian tubes, with or without one or both ovaries.

Selecting the correct CPT code is essential because 58571 is one of several closely related hysterectomy codes. Accurate reporting depends on factors such as the surgical approach, uterine weight, and whether the fallopian tubes or ovaries were removed, making thorough operative documentation and pathology findings critical for compliant coding and successful reimbursement.

58571 CPT Code Description Explained

The 58571 CPT code description refers to a total laparoscopic hysterectomy (TLH) performed on a uterus weighing 250 grams or less, with the removal of the fallopian tubes and/or ovaries. The procedure is carried out using a laparoscope and specialized surgical instruments inserted through small abdominal incisions, eliminating the need for a large open incision.

During the procedure, the surgeon laparoscopically detaches the uterus and cervix from the surrounding ligaments, blood vessels, and supporting tissues. If medically indicated, one or both fallopian tubes and ovaries may also be removed during the same operation. Once detached, the surgical specimen is typically removed through the vaginal canal or, when appropriate, through the laparoscopic ports.

Conditions Commonly Treated with CPT Code 58571

Healthcare providers may report CPT code 58571 when performing surgery for conditions such as:

• Uterine fibroids (leiomyomas)
• Abnormal uterine bleeding
• Endometriosis
• Adenomyosis
• Chronic pelvic pain
• Benign uterine tumors
• Other non-malignant uterine disorders requiring hysterectomy

Key Components of the Procedure

For a procedure to qualify for 58571, it should generally include the following:

• Minimally invasive laparoscopic approach
• Complete removal of the uterus and cervix
• Uterine weight of 250 grams or less, confirmed by the pathology report
• Removal of one or both fallopian tubes, with or without the ovaries
• Laparoscopic completion of the hysterectomy, including detachment of the uterus from its supporting structures

Understanding the complete 58571 CPT code description helps medical coders and billing professionals distinguish this procedure from other hysterectomy codes, ensuring accurate code selection, proper documentation, and compliant claim submission.

When Should CPT Code 58571 Be Used?

Selecting the correct CPT code depends on accurately identifying the surgical technique and the services performed. CPT code 58571 should be reported only when a total laparoscopic hysterectomy is completed for a uterus weighing 250 grams or less, with the removal of the fallopian tubes and/or ovaries. Using this code for procedures that do not meet these criteria may result in coding errors, claim denials, or reimbursement delays.

Before assigning 58571, coders should verify the operative report and pathology findings to ensure the procedure aligns with the code descriptor. The pathology report is particularly important because it confirms the uterine weight, which is a determining factor in selecting the appropriate hysterectomy CPT code.

Use CPT Code 58571 When:

• The procedure is performed using a laparoscopic surgical approach.
• A total hysterectomy is completed, including removal of the uterus and cervix.
• The uterus weighs 250 grams or less, as confirmed by the pathology report.
• One or both fallopian tubes are removed, with or without removal of one or both ovaries.
• The operative documentation clearly supports the services performed.

Do Not Use CPT Code 58571 When:

• The uterus weighs more than 250 grams (consider the appropriate higher-weight hysterectomy code).
• A laparoscopic-assisted vaginal hysterectomy (LAVH) is performed instead of a total laparoscopic hysterectomy.
• A supracervical hysterectomy is performed, leaving the cervix intact.
• The hysterectomy is completed using an open abdominal or vaginal surgical approach rather than laparoscopy.

Accurate code selection requires careful review of the operative note, pathology report, and surgical documentation. Confirming these details before claim submission helps reduce coding discrepancies, supports medical necessity, and improves the likelihood of timely reimbursement.

CPT Code 58571 vs. Related Hysterectomy CPT Codes

One of the most common coding mistakes is selecting the wrong hysterectomy CPT code. Although these procedures may appear similar, they differ based on the surgical approach, uterine weight, and whether the fallopian tubes and/or ovaries are removed. Reviewing the operative report and pathology findings is essential before assigning CPT code 58571.

The table below highlights the key differences between 58571 and other commonly reported laparoscopic hysterectomy codes.

Key Differences to Remember

• 58570 vs. 58571: Both describe a total laparoscopic hysterectomy for a uterus weighing 250 grams or less, but 58571 additionally includes the removal of the fallopian tubes and/or ovaries.
• 58571 vs. 58572: The primary distinction is uterine weight. Code 58572 is reported only when the uterus weighs more than 250 grams.
• 58571 vs. 58573: Both include adnexal removal, but 58573 applies to procedures involving a uterus greater than 250 grams.
• 58571 vs. 58552: 58571 is used for a total laparoscopic hysterectomy (TLH), while 58552 describes a laparoscopic-assisted vaginal hysterectomy (LAVH), where part of the procedure is completed vaginally.

Correctly distinguishing these codes helps ensure accurate claim submission, reduces coding errors, and minimizes reimbursement delays. When documentation is unclear, coders should verify the operative report and pathology findings before assigning the final CPT code.

Documentation Requirements for CPT Code 58571

Accurate documentation is the foundation of correct coding and successful reimbursement for CPT code 58571. Even when the appropriate procedure is performed, incomplete or unclear documentation can lead to claim denials, delayed payments, or payer audits. Medical coders should review both the operative report and the pathology report before assigning this code to ensure all coding criteria are met.

To support 58571 CPT code billing, the medical record should clearly document the surgical approach, the structures removed, and the pathology-confirmed uterine weight. These details help establish medical necessity while distinguishing 58571 from other hysterectomy CPT codes.

Documentation Checklist for CPT Code 58571

Ensure the patient’s record includes the following:

• Medical necessity supporting the need for a total laparoscopic hysterectomy.
• Operative report confirming a total laparoscopic surgical approach.
• Documentation that the uterus and cervix were completely removed.
• Confirmation that one or both fallopian tubes and/or ovaries were removed, when applicable.
• Pathology report verifying the uterus weighs 250 grams or less.
• Relevant preoperative and postoperative diagnoses.
• Details of any additional procedures or intraoperative findings.
• Clear surgeon documentation supporting the selected CPT code and any modifiers used.

Taking the time to verify these elements before claim submission can significantly reduce coding errors and improve first-pass claim acceptance. Thorough documentation also provides strong support during payer reviews, audits, or appeals, helping practices receive accurate and timely reimbursement.

Modifier Guidelines for CPT Code 58571

Correct modifier usage is essential when reporting CPT code 58571, as it provides additional information about the procedure performed and helps prevent unnecessary claim denials. Modifiers should only be appended when supported by the operative report and payer-specific billing guidelines. Incorrect or unsupported modifier use can delay reimbursement or trigger claim audits.

Below are the modifiers most commonly associated with 58571 CPT code and the situations in which they may be appropriate.

Modifier Best Practices

To reduce coding errors and improve claim acceptance:

• Only append modifiers when the medical documentation fully supports their use.
• Verify payer-specific policies, as modifier requirements may vary among insurers.
• Include detailed operative notes when reporting Modifier 22 or other complexity-related modifiers.
• Review National Correct Coding Initiative (NCCI) edits before billing multiple procedures together.

Applying the appropriate modifier to CPT code 58571 ensures that the claim accurately reflects the services provided, helping practices avoid reimbursement delays while maintaining coding compliance.

Common ICD-10 Diagnosis Codes That Support Medical Necessity

Selecting the correct diagnosis code is just as important as assigning the appropriate 58571 CPT code. The reported ICD-10-CM code should accurately reflect the patient’s documented condition and establish the medical necessity for performing a total laparoscopic hysterectomy. Using an unsupported or incorrect diagnosis code may result in claim denials, delayed reimbursement, or requests for additional documentation.

While the exact diagnosis varies by patient, the following ICD-10 codes are among the most commonly reported with CPT code 58571.

Best Practices for ICD-10 Coding

To support accurate billing and reimbursement:

• Select the ICD-10 code that best matches the documented diagnosis.
• Ensure the diagnosis is supported by the patient’s medical records and physician documentation.
• Verify payer-specific coverage policies, as medical necessity requirements may vary.
• Avoid using unspecified diagnosis codes when a more specific code is available and supported by documentation.

Accurate diagnosis coding, combined with complete clinical documentation, strengthens medical necessity and improves the likelihood of first-pass claim approval for CPT code 58571.

Common ICD-10 Diagnosis Codes That Support Medical Necessity

Selecting the correct diagnosis code is just as important as assigning the appropriate 58571 CPT code. The reported ICD-10-CM code should accurately reflect the patient’s documented condition and establish the medical necessity for performing a total laparoscopic hysterectomy. Using an unsupported or incorrect diagnosis code may result in claim denials, delayed reimbursement, or requests for additional documentation.

While the exact diagnosis varies by patient, the following ICD-10 codes are among the most commonly reported with CPT code 58571.

Best Practices for ICD-10 Coding

To support accurate billing and reimbursement:

• Select the ICD-10 code that best matches the documented diagnosis.
• Ensure the diagnosis is supported by the patient’s medical records and physician documentation.
• Verify payer-specific coverage policies, as medical necessity requirements may vary.
• Avoid using unspecified diagnosis codes when a more specific code is available and supported by documentation.

Accurate diagnosis coding, combined with complete clinical documentation, strengthens medical necessity and improves the likelihood of first-pass claim approval for CPT code 58571.

Billing Guidelines and Medicare Reimbursement Considerations

Accurate billing for CPT code 58571 requires proper documentation, correct diagnosis coding, and appropriate modifier usage. Before submitting a claim, providers should verify that the operative report and pathology findings support the selected CPT code while ensuring all payer-specific billing requirements are met.

CPT code 58571 typically carries a 90-day global surgical period under Medicare, and reimbursement varies based on the place of service, geographic location, and payer policies. Practices should also confirm prior authorization requirements when billing commercial insurers.

Accurate coding and timely claim submission are key to maximizing reimbursement and minimizing denials. For practices seeking to improve billing efficiency and revenue cycle performance, partnering with professional Medical Billing Services can help ensure cleaner claims, faster payments, and fewer coding-related issues.

Common Billing Errors and How to Avoid Them

Incorrect coding and incomplete documentation are among the leading causes of claim denials for CPT code 58571. Common mistakes include selecting the wrong hysterectomy code, reporting an incorrect uterine weight, using unsupported modifiers, or failing to document the surgical approach and pathology findings.

To reduce billing errors, review the operative report carefully, confirm the pathology-confirmed uterine weight, assign the appropriate ICD-10 diagnosis code, and verify all payer-specific billing requirements before claim submission. Taking these steps can improve first-pass claim acceptance and reduce reimbursement delays.

Final Thoughts

Understanding the 58571 CPT code is essential for accurate coding, compliant billing, and timely reimbursement. By selecting the correct CPT code, maintaining complete documentation, and following payer guidelines, healthcare providers can minimize claim denials and strengthen their revenue cycle.

Whether you’re a medical coder, biller, or healthcare provider, staying updated on current coding requirements ensures cleaner claims and improved financial outcomes for your practice.

FAQs

1. What is the 58571 CPT code used for?

CPT code 58571 is used to report a total laparoscopic hysterectomy for a uterus weighing 250 grams or less, including the removal of the fallopian tubes, with or without the ovaries.

2. What is the official 58571 CPT code description?

The 58571 CPT code description is: Laparoscopy, surgical, with total hysterectomy, for uterus 250 grams or less, with removal of tube(s) and/or ovary(s).

3. What is the difference between CPT code 58570 and 58571?

Both codes describe a total laparoscopic hysterectomy for a uterus weighing 250 grams or less. However, 58571 includes the removal of the fallopian tubes and/or ovaries, while 58570 does not.

4. What documentation is required for CPT code 58571?

Providers should document the laparoscopic surgical approach, removal of the uterus and cervix, pathology-confirmed uterine weight, any adnexal removal, medical necessity, and applicable diagnosis codes to support accurate billing.

5. What is the global period for CPT code 58571?

CPT code 58571 generally has a 90-day global surgical period under Medicare, during which routine postoperative care related to the procedure is included in the surgical payment.