CPT code 58262 – Vaginal hysterectomy with adnexal removal

Key takeaways

CPT code 58262 covers vaginal hysterectomy with tube or ovary removal when the uterus weighs 250 g or less. The operative report must record that weight.

Laparoscopic cases never use 58262. Total laparoscopic hysterectomy is CPT 58570 without adnexa or CPT 58571 with adnexa.

NCCI edits bundle lysis of adhesions and routine surgical steps into 58262. A separately reportable procedure, such as a sling (57288), needs modifier 51 or 59 and supporting documentation.

Robotic assistance is reported with HCPCS code S2900 on its own claim line, not as a modifier, and only where the payer accepts it.

Pabau, the practice management platform we build, checks each claim for required details like authorization codes before it goes out through Claim.MD.

What is CPT code 58262?

CPT code 58262 is the surgical procedure code for vaginal hysterectomy with removal of tube(s) and/or ovary(ies) when the uterus weighs 250 g or less. The American Medical Association’s CPT code set places it in the female genital system subsection of the surgery chapter. It sits between 58260, the same procedure without adnexal removal, and 58263, which adds repair of enterocele.

Three elements must be documented to support this code. The operative report needs the vaginal approach, removal of at least one fallopian tube or ovary, and a uterus weight at or below 250 g. If any one is missing, the claim will be denied outright or downgraded to an adjacent code.

Official descriptor and code family position

The AMA descriptor reads: “Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(ies).” The parent code 58260 covers the same weight class without adnexal removal. Codes 58290 through 58294 apply when the uterus exceeds 250 g. This weight-based split structures the whole vaginal hysterectomy family, and it is the first check an auditor runs.

Procedure overview: What the surgery involves

A vaginal hysterectomy proceeds entirely through the vaginal canal, with no abdominal incision. The surgeon detaches the uterus from its supporting ligaments, divides the uterine vessels, and removes the specimen through the vagina. Under CPT code 58262, the surgeon also removes at least one fallopian tube or ovary during the same operative session.

The operative report must document each of these steps to support the code:

1. Confirmation of vaginal approach, with no laparoscopic or abdominal incision
2. Division and ligation of the uterine vessels via the vaginal route
3. Specimen removal through the vagina, with the pathology specimen submitted
4. Explicit notation that at least one tube or ovary was removed
5. Pathology report confirming specimen weight at or below 250 g

If the operative note says “laparoscopic assistance” or doesn’t specify the approach, the case may belong to a different code family entirely. Coders shouldn’t infer a vaginal approach from the procedure title alone.

How CPT 58262 differs from neighboring codes

The vaginal and laparoscopic hysterectomy code families overlap heavily in clinical appearance. The table below maps the most commonly confused codes across three decision axes: Approach, uterus weight, and adnexal removal.

Read as a decision, the same codes resolve in three questions, asked in the order shown below.

Laparoscopic variants: CPT 58570 and 58571

CPT 58570 and 58571 describe total laparoscopic hysterectomy, where uterine detachment and removal are both performed laparoscopically. CPT code 58262 is strictly for the vaginal approach. The uterus is detached and removed through the vaginal canal without laparoscopic assistance. If the surgeon uses a laparoscope for any portion of the detachment, the case shifts to 58552 or 58571, depending on technique.

The operative note phrases to watch for are “laparoscope was introduced” and “laparoscopic assistance was used.” Either phrase removes the case from the 58262 category, even if the specimen came out vaginally.

Robotic-assisted hysterectomy: Reporting S2900 with CPT 58262

Robotic-assisted vaginal hysterectomy has no CPT code of its own. When a robotic system assists a vaginal approach, CPT code 58262 remains the procedure code. Some payers accept HCPCS Level II code S2900 for the robotic surgical system, reported as a separate line item alongside 58262.

S2900 is an add-on code, not a modifier, so it is never appended to the 58262 line. Other payers limit robotic billing to the facility claim and don’t recognize S2900 at the professional fee level. Check the payer’s policy before reporting it, because acceptance varies between commercial plans and Medicare Advantage plans.

ICD-10 diagnosis codes paired with CPT 58262

Medical necessity for CPT code 58262 requires an ICD-10-CM diagnosis that justifies both the hysterectomy and the adnexal removal. The most commonly paired codes are listed below. Payer LCDs and NCDs govern which diagnoses are accepted, so check the plan’s coverage policy before submitting.

Medicare reimbursement and RVUs for CPT 58262

Under the CMS Medicare Physician Fee Schedule, CPT code 58262 carries 15.54 work RVUs and a 90-day global surgical period. Payment also depends on practice expense and malpractice RVUs, the annual conversion factor, and geographic adjustments. Those inputs change every year and differ by locality, so this guide doesn’t quote a national dollar figure.

For current facility and non-facility values in your locality, search 58262 in the CMS PFS Look-Up Tool. Private payer contracts often reimburse at a multiple of Medicare rates, and each contract sets its own terms.

Prior authorization requirements

Medicare fee-for-service does not require prior authorization for CPT code 58262 as a routine rule, but Medicare Advantage plans and most commercial insurers do. Requirements vary by plan, and clinical criteria differ between carriers. The documentation supporting an authorization request should include:

• Confirmed diagnosis with ICD-10-CM code(s) and clinical rationale
• Evidence of failed or inappropriate conservative management (hormonal therapy, ablation, watchful waiting where applicable)
• Operative plan describing vaginal approach, anticipated adnexal removal, and estimated uterus weight based on imaging
• Preoperative imaging report (ultrasound or MRI noting uterus size)

Medicaid prior authorization thresholds vary by state. Some state Medicaid programs have moved gynecologic surgery to a managed-care authorization model. There, the managed-care organization sets the criteria, not the state fee-for-service program. Always verify with the specific plan before scheduling.

Strong medical billing compliance processes cut last-minute denials, and tracking authorization status before the case is one of the simplest.

NCCI edits, bundling, and add-on codes

The National Correct Coding Initiative (NCCI) bundles several services into CPT code 58262 as included components. Billing them separately without a supporting modifier counts as unbundling and triggers an automatic edit denial.

These services are commonly bundled into 58262 and aren’t separately billable unless an exception applies:

• Lysis of adhesions performed incidental to the hysterectomy (included in the surgical package)
• Routine vaginal cuff closure
• Urethral catheter placement (included)
• Simple adnexal adhesiolysis within the operative field

These procedures may be billed alongside CPT code 58262 with the correct modifier:

Global surgical period and post-op billing

CPT code 58262 carries a 90-day global surgical period under CMS MPFS rules. Routine postoperative care during the 90 days after the operative date is part of the global package. That includes wound checks, surgery-related medication management, and follow-up visits tied to the hysterectomy, and none of it can be billed separately.

Visits that are separately billable during the 90-day global period need modifiers to signal their independence:

• Modifier 24: Unrelated evaluation and management service during the postoperative period, such as an acute respiratory infection unrelated to the hysterectomy
• Modifier 25: Significant, separately identifiable E/M service on the same day as a minor surgical procedure. It applies before a procedure, not to post-op visits after major surgery.
• Modifier 79: Unrelated procedure during the postoperative period, such as a new surgical problem requiring a separate operation
• Modifier 55: Used when the operating surgeon transfers postoperative management to another physician. The physician taking over post-op care bills with modifier 55, and the surgeon bills with modifier 54.

Tracking the global period is core to revenue cycle management for surgical practices. A billing team that loses sight of the 90-day window will either hold back legitimate claims or miss the modifier on a genuinely unrelated service.

Documentation requirements for clean claims

A clean claim for CPT code 58262 depends on five specific data points in the operative report. Missing any one of them is enough for a payer to request more documentation or deny the first submission.

1. Vaginal approach confirmed: The note must state explicitly that the procedure was performed vaginally. Phrases like “no laparoscopic assistance” or “entirely vaginal approach” remove ambiguity.
2. Specimen weight recorded: The pathology request or intraoperative weight must document the uterus at or below 250 g. If only an imaging weight is available, some payers require a qualifier noting it is an estimate.
3. Adnexal removal documented: The note must name each structure removed, such as the left fallopian tube, the right ovary, or bilateral tubes and ovaries. Some payers reject “adnexa removed” on its own.
4. Pathology specimen submitted: A pathology order in the record confirms the specimen was sent, which corroborates both the removal and the weight.
5. Diagnosis linkage: The operative note’s indication section must reference the same condition as the ICD-10-CM code on the claim. A mismatch between the two is a leading soft denial trigger.

Common claim denial reasons for CPT code 58262

Denial patterns for CPT code 58262 cluster around five root causes. Denial management workflows that address each cause before submission cost less than working appeals after the fact.

Tracking denials by root cause, rather than by payer alone, gives OB/GYN billing teams a clearer point to intervene. For the reason codes payers return on ERAs, see the guide to medical billing denial codes.

How claims management software prevents CPT 58262 denials

Most 58262 denials start before submission. A missing authorization, a pathology weight the coder never saw, or incomplete payer details can each send the claim back. Billing teams without a checking step catch these only when the rejection arrives.

Pabau includes claims software for gynecologists and other surgical practices, and it runs validation checks each time a claim is about to go out. If a required detail such as an authorization code is missing, the Send button stays disabled until the claim is complete.

Through its Claim.MD integration, Pabau submits the claim electronically as a CMS-1500, checks patient eligibility in real time, and tracks each claim’s status. ERA remittances flow back into the same dashboard, so your team can match 58262 payments against what the practice expected.

Reduce claim denials for surgical procedures

Pabau checks each claim for required details like authorization codes, then sends it through Claim.MD. OB/GYN practices spend less time reworking hysterectomy claims.

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Conclusion

For 58262, the coding decision lives in the pathology report and the op note more than in the procedure title. Holding the claim until the weight comes back, and reading the note for any laparoscope, prevents most wrong-code denials.

The trade-off is a short billing lag on each case. That lag costs far less than reworking a denied hysterectomy claim and waiting on the appeal.

Book a demo to see how Pabau keeps authorization details, claim status, and remittances in one place for gynecologic surgery billing.

Continue your research

Coding a laparoscopic case instead? CPT code 58571 covers total laparoscopic hysterectomy with tube or ovary removal for a uterus 250 g or less.

Was the uterus removed through an abdominal incision? CPT code 58150 walks through total abdominal hysterectomy billing and its documentation requirements.

Billing the anesthesia side of the case? CPT code 00944 explains anesthesia coding for vaginal hysterectomy.

Removing the adnexa in a separate session? CPT code 58661 covers laparoscopic removal of adnexal structures and when it is reported on its own.

Supporting a hysterectomy for abnormal bleeding? ICD-10 code N93.9 covers unspecified abnormal uterine and vaginal bleeding and how to document it.

Frequently asked questions