How To Use CPT Code 58570

CPT 58570 is a surgical code for laparoscopic total hysterectomy for a uterus weighing 250 g or less. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 58570.

1. What is CPT 58570?

CPT 58570 is a medical billing code used to describe a laparoscopic total hysterectomy procedure performed on a uterus weighing 250 grams or less. This code is used by medical coders and billers to accurately report and bill for this specific surgical procedure.

2. 58570 CPT code description

The official description of CPT code 58570 is: “Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less.”

3. Procedure

  1. The patient is placed in the dorsal lithotomy position, and the abdomen is prepped and draped.
  2. 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. A combination uterine manipulator-colpotomizer device is placed into the uterus through the cervix for manipulation and guidance during the procedure.
  7. The course of the ureters is identified, and they are dissected free to prevent damage during surgery.
  8. Ovarian ligaments and veins between the ovary and round ligaments are desiccated using a heated instrument.
  9. Round ligaments are incised, and the uterus is dissected from the anterior and posterior broad ligament.
  10. Ovarian ligaments are incised with a scalpel, and the bladder is mobilized off the lower uterine segment.
  11. Uterine arteries are stripped from surrounding tissue and ligated.
  12. Cardinal and uterosacral ligaments are incised and clamped.
  13. A circular incision is made around the anterior and posterior vagina using the colpotomizer as a guide.
  14. The uterus and cervix are removed through the vagina or via trocar ports if morcellation is necessary.
  15. A sponge or other device is placed into the vaginal cuff area, and the abdominal cavity is reinflated.
  16. The vaginal cuff is sutured through the laparoscope, and uterosacral tissues are folded and shortened to prevent enterocele formation.
  17. The provider confirms there is no bleeding, deflates the abdomen, and removes all instruments and trocars.
  18. Trocar sites are closed with sutures at the level of both the fascia and the skin.

4. Qualifying circumstances

Patients eligible to receive CPT code 58570 services are those who require a total hysterectomy due to medical conditions such as uterine fibroids, endometriosis, chronic pelvic pain, or abnormal uterine bleeding, and have a uterus weighing 250 grams or less. The patient must be a suitable candidate for laparoscopic surgery, and the provider must determine that a total hysterectomy is the most appropriate treatment option.

5. When to use CPT code 58570

It is appropriate to bill the 58570 CPT code when a laparoscopic total hysterectomy is performed on a patient with a uterus weighing 250 grams or less, and all connections are severed through the scope. The uterus must be removed through the scope by cutting it into small pieces or through the vaginal canal, and the vaginal cuff must be sewn from above through the laparoscope.

6. Documentation requirements

To support a claim for CPT 58570, the following information must be documented in the patient’s medical record:

  • Indication for the total hysterectomy (e.g., uterine fibroids, endometriosis, chronic pelvic pain, or abnormal uterine bleeding)
  • Weight of the uterus (must be 250 grams or less)
  • Details of the laparoscopic total hysterectomy procedure, including all steps performed
  • Method of uterus removal (through the scope or vaginal canal)
  • Confirmation that the vaginal cuff was sewn from above through the laparoscope
  • Postoperative care instructions and follow-up plan

7. Billing guidelines

When billing for CPT code 58570, it is essential to ensure that the patient’s medical record contains all required documentation to support the claim. Additionally, be aware of any payer-specific guidelines or requirements related to billing for this code. It is also crucial to verify that the patient meets the eligibility criteria for this procedure, including having a uterus weighing 250 grams or less.

8. Historical information

CPT 58570 was added to the Current Procedural Terminology system on January 1, 2008. The code was changed on January 1, 2010, with the previous descriptor being “Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less.”

9. Similar codes to CPT 58570

Five similar codes to CPT 58570 and how they differentiate are:

  1. CPT 58571: This code is used for laparoscopic total hysterectomy with removal of tubes and/or ovaries for a uterus weighing 250 grams or less.
  2. CPT 58572: This code is used for laparoscopic total hysterectomy for a uterus weighing more than 250 grams but less than or equal to 500 grams.
  3. CPT 58573: This code is used for laparoscopic total hysterectomy with removal of tubes and/or ovaries for a uterus weighing more than 250 grams but less than or equal to 500 grams.
  4. CPT 58550: This code is used for laparoscopic vaginal hysterectomy for a uterus weighing 250 grams or less.
  5. CPT 58552: This code is used for laparoscopic vaginal hysterectomy with removal of tubes and/or ovaries for a uterus weighing 250 grams or less.

10. Examples

Here are 10 detailed examples of CPT code 58570 procedures:

  1. A 40-year-old woman with a history of uterine fibroids undergoes a laparoscopic total hysterectomy for a uterus weighing 200 grams.
  2. A 35-year-old woman with endometriosis and a uterus weighing 225 grams undergoes a laparoscopic total hysterectomy.
  3. A 45-year-old woman with chronic pelvic pain and a uterus weighing 240 grams undergoes a laparoscopic total hysterectomy.
  4. A 38-year-old woman with abnormal uterine bleeding and a uterus weighing 230 grams undergoes a laparoscopic total hysterectomy.
  5. A 42-year-old woman with a history of uterine fibroids and a uterus weighing 210 grams undergoes a laparoscopic total hysterectomy.
  6. A 37-year-old woman with endometriosis and a uterus weighing 220 grams undergoes a laparoscopic total hysterectomy.
  7. A 47-year-old woman with chronic pelvic pain and a uterus weighing 235 grams undergoes a laparoscopic total hysterectomy.
  8. A 39-year-old woman with abnormal uterine bleeding and a uterus weighing 245 grams undergoes a laparoscopic total hysterectomy.
  9. A 43-year-old woman with a history of uterine fibroids and a uterus weighing 215 grams undergoes a laparoscopic total hysterectomy.
  10. A 36-year-old woman with endometriosis and a uterus weighing 225 grams undergoes a laparoscopic total hysterectomy.

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