Uterine fibroids continue to be among the most frequent causes of gynecologic surgical intervention in women, and laparoscopic myomectomy has been the surgical method of choice in both fertility preservation and symptomatic growths of fibroid.
With the ever-increasing use of minimally invasive procedures to replace open procedures, proper coding of this surgery has become more critical to practices submitting bills to gynecologic services.
The coders and practices in ob-gyn should have a guideline on the identification of the eligible cases, proper application of modifiers, and documentation requirements.
CPT 58545 Definition: Laparoscopic Myomectomy Coding Explained
This code is only used in the case of a minimum invasive fibroid removal procedure with an exact clinical definition provided by AMA.
CPT Code 58545 - Laparoscopy, surgical, myomectomy, excision; 1-4 intramural myomas total weight of 250g or less/or, surface myoma removal. In practice, this code explains a laparoscopic surgery where the surgeon removes one to four fibroids attached to the inner muscle wall of the uterus (intramural), with a total weight of 250 grams, and/or the removal of fibroids attached to the surface of the uterus (subserosal myomas), using a minimally invasive laparoscopic instrument instead of an open
incision.
Laparoscopic myomectomy is likely the most frequently used short description by CMS and payers of this code. It is a Category I CPT code that is upheld by the AMA in the Surgery subsection, under Laparoscopic/Hysteroscopic Procedures on the Corpus Uteri, and is current (Status A) in 2025-2026 on the Medicare Physician Fee Schedule.
When to Use CPT 58545 for Laparoscopic Fibroid Removal
Reporting of this code ought to be based on certain clinical thresholds of the procedure and fibroid characteristics.
- The number of intramural fibroids is 1-4 and the weight is 250 grams or less.
- The process involves extraction of surface (subserosal) myoma, either as a solitary nodule or both in conjunction with intramural fibroids but within the weight limit.
- Fibroids are symptomatic and may lead to abnormal bleeding, pain in the pelvis, the pressure, or infertility, which can be ordered by imaging, or even clinical examination.
- The whole process is carried out laparoscopically without turning to an open surgery.
- The aim of the surgery is to preserve the uterus, which differentiates this stage of surgery and hysterectomy.
When Not to Use CPT 58545 in Gynecologic Surgery Coding
There are a few scenarios that are not covered by this code and which demand a different choice of CPT.
- Five or more intramural myomas, or a total fibroid weight exceeding 250 grams - report CPT 58546 instead.
- Myomectomy performed through an open abdominal incision - use codes 58140--58146 rather than 58545.
- Myomectomy performed via a vaginal approach rather than laparoscopically.
- Hysterectomy performed instead of, or in addition to, myomectomy in the same session.
- Procedures bundled with 58545 under NCCI edits or CPT parenthetical notes, such as certain hysterectomy codes or CPT 58674, unless a separately reportable service is clearly documented.
Modifiers for CPT 58545 Laparoscopic Myomectomy Claims
The proper use of modifiers aids in displaying the complexity of the procedure and preventing any rejection of claims based on bundling corrections.
- Modifier 22 - Increased procedural complexity, such as an unusually difficult fibroid burden or extended operative time.
- Modifier 51 - Reported when CPT 58545 is billed alongside other significant, separately identifiable procedures during the same operative session.
- Modifier 59 / X{EPSU} - Applied when a distinct procedural service is performed that is not otherwise bundled, when supported by documentation.
- Modifier 78 - Used for an unplanned return to the operating room during the 90-day global period for a complication related to the original myomectomy.
- Modifier 79 - Used for a staged or unrelated procedure performed by the same physician during the global period.
Documentation Requirements for CPT 58545 Coding Accuracy
Medical necessity and proper code selection require complete documentation of operative and pathology.
- Total fibroids removed and type (intramural or surface, subserosal).
- Weight or estimated size of fibroid total, which would verify that the case is below the 250-gram limit.
- Assurance that there has been no conversion of the operation to open surgery, and the entire surgery was done laparoscopically.
- Preoperative imaging (ultrasound or MRI) to support the diagnosis and symptomatic indication to surgery.
- Operative report information of port placement, fibroid enucleation, hemostatic method, and specimen retrieval, and morcellation method when utilized.
- Pathology report that the excised tissue is leiomyoma (fibroid).
Reimbursement Guidelines for CPT 58545 Under Medicare PFS
Payment for this procedure is governed by CMS policy and is subject to standard surgical This procedure is under CMS policy and subject to standard surgical claim edits to payment.
- Code would be A (Active) in the Medicare Physician fee schedule and charged.
- Includes 90 days worldwide surgery package, which, in other words, includes typical postoperative care as part of the package.
- Ranges of approximately all-country payment: $800-880 (facility/non-facility) but can vary per year, locality, and GPCI.
- Work RVU is estimated at about 15 which indicates the surgical intensity of the procedure.
- Edit under National Correct Coding Initiative (NCCI) and local Local Coverage Determinations (LCDs), as necessary.
- Repayment is based on documented medical necessity, e.g. symptomatic fibroids resulting in bleeding, pain or fertility issues.
Common CPT 58545 Coding Scenarios in Gynecologic Practice
Examining practical coding examples can be viewed as an effective method of clarifying how laparoscopic myomectomy claims should be properly coded and what modifiers to utilize.
- Scenario 1 - A patient has three intramural fibroids that weigh 180 grams, and has experienced heavy menstrual bleeding. The surgeon does only a complete laparoscopy myomectomy. CPT 58545 is reported individually with documentation of fibroid count, weight and laparoscopic method of approach.
- Scenario 2 - A patient has two intramural fibroids (150 grams total) and an extra surface fibroid removed with laparoscopic surgery. As the case is at the boundary of 4 fibroids and 250 grams, CPT 58545 will absorb the intramural and surface fibroid ablation.
- Scenario 3 - A surgeon starts with the laparoscopic procedure but becomes switched to an open one because the later surgery is excessively bleeding. CPT 58545 is outdated; the claim form should have the correct open myomectomy code (58140-58146) and the conversion made noted.
- Scenario 4 - When a patient was found to have six intramural fibroids with a total weight of 300 grams. Since the case exceeds the fibroid number and weight requirements to qualify under the category of CPT 58545, the right code would be CPT 58546.
- Scenario 5 - The patient evidence is that a laparoscopic myomectomy patient presented to the operating room 10 days following the operation because of postoperative bleeding at the incision. Given that it falls under the 90 day global period, a modifier 78 is added to the corresponding procedure code instead of resubmission of CPT 58545 to represent a different myomectomy.
98% Clean Claim Rate: How CureCloudMD Powers Laparoscopic Myomectomy Billing
Correct coding involving operations such as laparoscopic myomectomy should be based on expertise in that area, which CureCloudMD can provide to all claims of gynecologic surgeries.
The codes of laparoscopic myomectomy are closely dependent on the number of fibroid, weight criteria, bundling regulations, and minor documentation errors may cause unnecessary reimbursement loss. CureCloudMD maintains a certified coding staff who is up to date with both CMS updates, NCCI edits, as well as individual payer-related policies, practices in the gynecologic surgery field, thereby submitting clean claims through the first filing.
In addition to providing code selections, CureCloudMD provides OBGYN practices with documentation review services, modifier accuracy check services, and denials management based upon laparoscopic and open gynecologic surgeries. This specialty approach assists practices in lessening the administrative load without limiting, but assuring reimbursement of fibroid related surgical treatment.
- 98%+ Clean Claim Rate - Reported performance indicator across gynecologic surgery claims.
- Below 1% Average Denial Rate - Reflecting proactive documentation and coding review before claim submission.
- Dedicated Gynecology Coding Expertise - Supported by specialty-trained coders familiar with laparoscopic and open gynecologic procedures.
- Faster Reimbursement Turnaround - Through consistent claim accuracy and reduced rework.
Accurate procedure coding such as laparoscopic myomectomy safeguards profits and adherence and such accuracy is what CureCloud MD delivers to gynecologic surgery billing on a daily basis. Practices seeking to minimize the denials, expedite documentation review and sustain consistent reimbursements of fibroid-related procedures may consult CureCloudMD, with specialty-trained, team of coders to handle the specifics of claim submission to payment.
