Hysterectomy Coding: Approach, Uterus Weight, and Adnexa — the Three Axes
Hysterectomy has one of the most systematic code families in CPT. Each code is defined by three simultaneous axes:
- Approach: abdominal, vaginal, laparoscopic/robotic, or laparoscopically assisted vaginal
- Uterus weight: 250 g or less vs. greater than 250 g (from pathology)
- Adnexa: with or without removal of tubes and/or ovaries
A total laparoscopic hysterectomy of a 180 g uterus with bilateral salpingo-oophorectomy is 58571; the same operation for a 400 g uterus is 58573. The weight comes from the pathology report — document it, or the claim defaults to the lower-valued code.
The adnexa bundling trap
When the hysterectomy code you selected already includes removal of tubes/ovaries, do not also report a separate salpingo-oophorectomy code — that's a classic unbundling error. The BSO is inside the hysterectomy code.
Obstetric globals are packages
Routine OB care uses global codes (59400 vaginal, 59510 cesarean, 59610 VBAC) covering antepartum visits, delivery, and postpartum care. Delivery-only and antepartum-only codes exist solely for genuinely split care between practices — never unbundle a global package you provided in full.
Hysteroscopy bundling
Diagnostic hysteroscopy and D&C are included in operative hysteroscopy at the same session.
Clinical Capture extracts all three axes from the operative note — and asks for the uterus weight when the note doesn't state it, rather than guessing.
This article is educational and not coding, billing, or legal advice. Always verify codes and values against the current CPT®, ICD-10-CM, and CMS Physician Fee Schedule, follow NCCI edits and payer policy, and confirm with a certified coder before submitting a claim. Document only work that was actually performed.