How To Use CPT Code 58552

CPT 58552 refers to a laparoscopic surgical procedure with vaginal hysterectomy for a uterus weighing 250 g or less, including the removal of fallopian tubes and/or ovaries. This article will cover the description, procedure, qualifying circumstances, usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 58552.

1. What is CPT 58552?

CPT 58552 is a medical procedure code used to describe a laparoscopic surgical procedure combined with a vaginal hysterectomy for a uterus weighing 250 g or less. This code also includes the removal of fallopian tubes and/or ovaries during the procedure.

2. 58552 CPT code description

The official description of CPT code 58552 is: “Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)”.

3. Procedure

The 58552 procedure involves the following steps:

1. The patient is placed in the dorsal lithotomy position.
2. The abdomen is prepped and draped, and general anesthesia is administered.
3. The provider enters the abdominal cavity near the belly button using a Veress needle or an open incision and places a laparoscope.
4. The abdomen is insufflated with CO2 gas to create a pneumoperitoneum, and the patient is put into the Trendelenburg position.
5. Small incisions are made around the abdominal area to insert trocars for better visualization and insertion of surgical tools.
6. If robotic surgery is performed, the robot is docked to the laparoscope at this time.
7. A uterine manipulator is placed into the uterus to move it around during the procedure.
8. The infundibulopelvic ligaments on both sides are clamped, cauterized, and incised.
9. The round ligaments are identified, incised, and cauterized.
10. The broad ligament is incised, extending the incision downward toward the cervix.
11. The ureters, uterine artery, and vein are identified and incised close to the ureters.
12. The bladder is freed up.
13. After releasing the gas from the abdomen, the vaginal part of the procedure begins.
14. A circular incision is made in the vaginal wall around the cervix, entering the anterior and posterior cul-de-sac.
15. The uterosacral and cardinal ligaments are clamped and incised, freeing the uterus from the broad ligament.
16. The uterus, fallopian tubes, and ovaries (if applicable) are removed through the vagina.
17. Bleeding is controlled with cautery and sutures, and the vaginal cuff is closed from below.
18. The trocars are removed, and the abdominal incisions are closed with sutures.

4. Qualifying circumstances

Patients eligible to receive CPT code 58552 services are those with a uterus weighing 250 g or less who require a hysterectomy and removal of fallopian tubes and/or ovaries. The procedure is typically performed for medical reasons, such as uterine fibroids, endometriosis, or cancer.

5. When to use CPT code 58552

It is appropriate to bill the 58552 CPT code when a laparoscopic surgical procedure with vaginal hysterectomy is performed for a uterus weighing 250 g or less, including the removal of fallopian tubes and/or ovaries. The code should be used when the provider has documented the procedure and met all necessary requirements.

6. Documentation requirements

To support a claim for CPT 58552, the following information should be documented:

• Indication for the procedure (e.g., uterine fibroids, endometriosis, cancer)
• Weight of the uterus (must be 250 g or less)
• Details of the laparoscopic and vaginal portions of the procedure
• Removal of fallopian tubes and/or ovaries, if applicable
• Operative report, including a detailed description of the procedure and any complications

7. Billing guidelines

When billing for CPT code 58552, following the appropriate guidelines and rules is essential. Do not report 58550-58552 in conjunction with 49320, 57000, 57180, 57410, 58140-58146, 58545, 58546, 58561, 58661, 58670, or 58671. Ensure the documentation supports the claim and includes all necessary information.

8. Historical information

CPT 58552 is added to the Current Procedural Terminology system on January 1, 2003. The code was changed on January 1, 2007, with the previous descriptor being “Laparoscopy surgical, with vaginal hysterectomy, for uterus 250 grams or less; with removal of tube(s) and/or ovary(s)”.

9. Similar codes to CPT 58552

Five similar codes to CPT 58552 and how they differentiate are:

• CPT 58550: Laparoscopic surgical procedure with vaginal hysterectomy for uterus 250 g or less, without removal of tubes and/or ovaries.
• CPT 58553: Laparoscopic surgical procedure with vaginal hysterectomy for uterus weighing more than 250 g, with removal of tubes and/or ovaries.
• CPT 58554: Laparoscopic surgical procedure with vaginal hysterectomy for uterus weighing more than 250 g, without removal of tubes and/or ovaries.
• CPT 58570: Total laparoscopic hysterectomy for uterus 250 g or less, with or without removal of tubes and/or ovaries.
• CPT 58571: Total laparoscopic hysterectomy for uterus weighing more than 250 g, with or without removal of tubes and/or ovaries.

10. Examples

Here are 10 detailed examples of CPT code 58552 procedures:

1. A 40-year-old woman with symptomatic uterine fibroids undergoes a laparoscopic surgical procedure with vaginal hysterectomy and removal of fallopian tubes.
2. A 45-year-old woman with endometriosis has a laparoscopic surgical procedure with vaginal hysterectomy and removal of ovaries.
3. A 50-year-old woman with a history of abnormal uterine bleeding undergoes a laparoscopic surgical procedure with vaginal hysterectomy and removal of fallopian tubes and ovaries.
4. A 38-year-old woman with chronic pelvic pain and a small uterus undergoes a laparoscopic surgical procedure with vaginal hysterectomy and removal of fallopian tubes.
5. A 47-year-old woman with a history of ovarian cysts has a laparoscopic surgical procedure with vaginal hysterectomy and removal of ovaries.
6. A 42-year-old woman with a uterine prolapse undergoes a laparoscopic surgical procedure with vaginal hysterectomy and removal of fallopian tubes and ovaries.
7. A 48-year-old woman with adenomyosis has a laparoscopic surgical procedure with vaginal hysterectomy and removal of fallopian tubes.
8. A 52-year-old woman with a history of abnormal Pap smears undergoes a laparoscopic surgical procedure with vaginal hysterectomy and removal of ovaries.
9. A 37-year-old woman with a history of uterine polyps has a laparoscopic surgical procedure with vaginal hysterectomy and removal of fallopian tubes and ovaries.
10. A 46-year-old woman with a history of pelvic inflammatory disease undergoes a laparoscopic surgical procedure with vaginal hysterectomy and removal of fallopian tubes.