Surgery: Female Genital System (Q&A) (September 2015)

September 2015 page 12dd Surgery: Female Genital System Question: Is it appropriate to report CPT code 58548 , Laparoscopy, surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with removal of tube(s) and ovary(s), if performed , if laparoscopic hysterectomy with bilateral total pelvic lymphadenectomy is performed? Answer: Yes, it is appropriate to report CPT code 58548 for laparoscopic hysterectomy with bilateral total pelvic lymphadenectomy, as long as the operative report describes complete removal of pelvic lymph nodes, tubes and ovaries. Documentation in the medical records should support what was performed. Surgery: Female Genital System...

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Note:  The following article synopsis was NOT provided by the AMA. It was created by Find-A-Code/innoviHealth.

Article Overview

This article explains a coding question from CPT Assistant focused on female genital system surgery and laparoscopic hysterectomy reporting. It is relevant to surgical coders, gynecologic billing staff, and compliance reviewers who need to understand the general documentation and reporting considerations discussed in the Q&A. The piece centers on a specific CPT example and the type of operative detail expected in the record.

Why This Topic Matters

Surgical coding for gynecologic procedures depends on accurate operative documentation and correct identification of the reported service. This Q&A helps readers understand the scope of the discussion and the documentation emphasis surrounding a laparoscopic hysterectomy case.

Article Sections

  1. September 2015 page 12dd

    A brief publication reference identifying the issue and page location for the Q&A content.

  2. Surgery: Female Genital System

    A question-and-answer discussion focused on female genital system surgery coding and associated operative documentation considerations.

What You Will Learn

  • The general subject matter addressed in the CPT Assistant Q&A
  • How the article frames documentation support for a gynecologic surgical reporting question
  • Which type of surgical scenario the discussion is centered on
  • Why operative record detail is important in the context of the article

Who Should Read This

  • Medical coders
  • Gynecology billing staff
  • Compliance auditors
  • Revenue cycle professionals
  • Physician documentation reviewers

Codes Discussed


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