AAGL Center of Excellence in Minimally Invasive Gynecology Qualifying Procedures with CPT Codes¹

Hysteroscopic Procedures CPT Code Description 58559 , surgical; with lysis of intrauterine adhesions - moderate to severe 58560 Hysteroscopy, surgical; with division or resection of intrauterine septum Hysteroscopy, surgical; with removal of leiomyomata (submucosal myomectomy - Type 0, I, 58561 II) 58562 Hysteroscopy, surgical; with removal of impacted foreign body Hysteroscopy, surgical; with (eg, endometrial resection, electrosurgical 58563 ablation, thermoablation) Hysteroscopy, surgical; with bilateral cannulation to induce occlusion by 58565 placement of permanent implants

Laparoscopic Procedures All cases must have been performed laparoscopically or been -assisted to qualify. CPT Code Description 38500 Biopsy or excision of (s) 38562 Limited lymphadenectomy for staging (separate procedure); pelvic or para-aortic Limited lymphadenectomy for staging (separate procedure); retroperitoneal (aortic and/or 38564 splenic) Laparoscopy, surgical, appendectomy - for this procedure to qualify, an exploratory 44970 laparoscopy must have been performed on a patient who presented with abdominal pain and whose appendix was removed after ruling out gynecologic conditions Excision or destruction, intra-abdominal tumors, cysts or , 1 or more 49205 peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; largest tumor greater than 10.0 cm diameter 51990 Laparoscopy, surgical; urethral suspension for stress incontinence 51992 Laparoscopy, surgical; sling operation for stress incontinence (eg, fascia or synthetic) 57291 Construction of artificial ; without graft 57305 Closure of 57423 Paravaginal defect repair (including repair of , if performed), laparoscopic approach 57425 Laparoscopy, surgical, [sacro]colpopexy (suspension of vaginal apex) 57426 Revision (including removal) of prosthetic vaginal graft, laparoscopic approach 58541 Laparoscopy, surgical, supracervical (LSH), for 250 g or less Laparoscopy, surgical, supracervical hysterectomy (LSH), for uterus 250 g or less; with 58542 removal of tube(s) and/or (s) 58543 Laparoscopy, surgical, supracervical hysterectomy (LSH), for uterus greater than 250 g Laparoscopy, surgical, supracervical hysterectomy (LSH), for uterus greater than 250 g; with 58544 removal of tube(s) and/or ovary(s) Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 58545 250 g or less and/or removal of surface myomas Laparoscopy, surgical, myomectomy, excision; 5 or more intramural myomas and/or 58546 intramural myomas with total weight greater than 250 g Laparoscopy, surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy 58548 and para-aortic lymph node sampling (biopsy), with removal of tube(s) and ovary(s), if performed 58550 Laparoscopy, surgical, with vaginal hysterectomy (LAVH), for uterus 250 g or less Laparoscopy, surgical, with vaginal hysterectomy (LAVH), for uterus 250 g or less; with 58552 removal of tube(s) and/or ovary(s)

COEMIG Qualifying Procedures with CPT Codes Rev 01/2014 58553 Laparoscopy, surgical, with vaginal hysterectomy (LAVH), for uterus greater than 250 g Laparoscopy, surgical, with vaginal hysterectomy (LAVH), for uterus greater than 250 g; with 58554 removal of tube(s) and/or ovary(s) 58570 Laparoscopy, surgical, with total hysterectomy (TLH), for uterus 250 g or less Laparoscopy, surgical, with total hysterectomy (TLH), for uterus 250 g or less; with removal 58571 of tube(s) and/or ovary(s) 58572 Laparoscopy, surgical, with total hysterectomy (TLH), for uterus greater than 250 g Laparoscopy, surgical, with total hysterectomy (TLH), for uterus greater than 250 g; with 58573 removal of tube(s) and/or ovary(s) Laparoscopy, surgical; with removal of adnexal structures (partial or total 58661 and/or ) Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or 58662 peritoneal surface - qualify for ASRM Stage II, III, or IV 58672 Laparoscopy, surgical; with fimbrioplasty 58673 Laparoscopy, surgical; with salpingostomy (salpingoneostomy) 58700 Salpingectomy, complete or partial, unilateral or bilateral (separate procedure) 58720 Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure) 58750 Tubotubal anastomosis 58925 Ovarian cystectomy, unilateral or bilateral Oophorectomy, partial or total, unilateral or bilateral; for ovarian, tubal or primary peritoneal malignancy, with para-aortic and pelvic lymph node biopsies, peritoneal washings, peritoneal 58943 biopsies, diaphragmatic assessments, with or without salpingectomy(s), with or without omentectomy Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo- 58950 oophorectomy and omentectomy Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo- 58952 oophorectomy and omentectomy; with radical dissection for debulking (ie, radical excision or destruction, intra-abdominal or retroperitoneal tumors) Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine 58957 malignancy (intra-abdominal, retroperitoneal tumors), with omentectomy, if performed Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine 58958 malignancy (intra-abdominal, retroperitoneal tumors), with omentectomy; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy Staging or restaging of ovarian, tubal, or primary peritoneal malignancy (second look), with 58960 or without omentectomy, peritoneal washing, biopsy of abdominal and pelvic peritoneum, diaphragmatic assessment with pelvic and limited para-aortic lymphadenectomy

Vaginal Procedures CPT Code Description Urethrolysis, transvaginal, secondary, including cystourethroscopy (eg, postsurgical 53500 obstruction, scarring) 57106 (colpectomy), partial removal of vaginal wall 57110 Vaginectomy (colpectomy), complete removal of vaginal wall 57120 (Le Fort type) Insertion of mesh or other prosthesis for repair of defect, each site (anterior, 57267 posterior compartment), vaginal approach 57282 Colpopexy, vaginal; extra-peritoneal approach (sacrospinous, iliococcygeus) 57283 Colpopexy, vaginal; intra-peritoneal approach (uterosacral, levator myorrhaphy) 57285 Paravaginal defect repair (including repair of cystocele, if performed); vaginal approach 57287 Removal or revision of sling for stress incontinence (eg, fascia or synthetic) 57288 Sling operation for stress incontinence (eg, fascia or synthetic) 57295 Revision (including removal) of prosthetic vaginal graft; vaginal approach 57320 Closure of ; vaginal approach 57530 Trachelectomy (cervicectomy), amputation of (separate procedure)

COEMIG Qualifying Procedures with CPT Codes Rev 01/2014 Myomectomy, excision of fibroid tumors(s) of uterus, 1 to 4 intramural myoma(s) with total 58145 weight of 250 g or less and/or removal of surface myomas; vaginal approach 58260 Vaginal hysterectomy, for uterus 250 g or less 58262 Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s), with 58263 repair of enterocele Vaginal hysterectomy, for uterus 250 g or less; with colpo-urethrocystopexy (Marshall- 58267 Marchetti-Krantz type, Pereyra type) with or without endoscopic control 58270 Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele 58275 Vaginal hysterectomy, with total or partial vaginectomy 58280 Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele 58285 Vaginal hysterectomy, radical 58290 Vaginal hysterectomy, for uterus greater than 250 g 58291 Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s), 58292 with repair of enterocele Vaginal hysterectomy, for uterus greater than 250 g; with colpo-urethrocystopexy (Marshall- 58293 Marchetti-Krantz type, Pereyra type) with or without endoscopic control 58294 Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele

¹ Current Procedural Terminology (CPT®) codes and descriptions are copyright 2013 American Medical Association. All rights reserved.

COEMIG Qualifying Procedures with CPT Codes Rev 01/2014