How To Use CPT Code 58611

CPT 58611 is a code for ligation or transection of fallopian tube(s) during cesarean delivery or intra-abdominal surgery. This article will cover the description, procedure, qualifying circumstances, when to use the code, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 58611 procedures.

1. What is CPT 58611?

CPT 58611 is a code used to describe the ligation or transection of one or both fallopian tubes during a cesarean delivery or intra-abdominal surgery. This procedure is performed to prevent future pregnancies and is reported as an add-on code in addition to the primary procedure code.

2. 58611 CPT code description

The official description of CPT code 58611 is: Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra-abdominal surgery (not a separate procedure) (List separately in addition to code for primary procedure).

3. Procedure

  1. After the cesarean delivery, the provider closes the uterine incision with sutures.
  2. The provider grasps the fallopian tube with a clamp and passes a hemostat through the part of the fallopian tube that has a limited blood supply.
  3. She then places sutures through the opening she creates with the hemostat and ties the tube in two locations, leaving the ends of the suture thread long.
  4. The provider incises the section between the two sutures, removes a portion of the tube, and sends it to the laboratory for confirmation.
  5. Using a hemostat, the provider makes a hole into the muscular layer of the uterus.
  6. She takes the long thread ends of the suture in the tube closest to the hole and threads them into a needle, passing the needle into the hole and exiting the needle to the outside of the uterus. This is repeated so there are two suture ends.
  7. The provider ties the two sutures together, buries the end of the fallopian tube into the hole, and sutures the uterine lining closed over the hole and tube.
  8. She checks for bleeding and obtains hemostasis.
  9. Finally, the provider closes the abdominal incision made for the cesarean procedure.

4. Qualifying circumstances

Patients eligible to receive CPT code 58611 services are those who undergo a cesarean delivery or intra-abdominal surgery and require ligation or transection of one or both fallopian tubes to prevent future pregnancies. This procedure is typically performed as a sterilization method for women who have completed their desired family size or have medical conditions that make future pregnancies risky.

5. When to use CPT code 58611

It is appropriate to bill the 58611 CPT code when the provider performs ligation or transection of one or both fallopian tubes during a cesarean delivery or intra-abdominal surgery. This code should be used as an add-on code in addition to the primary procedure code for the cesarean delivery or intra-abdominal surgery.

6. Documentation requirements

To support a claim for CPT 58611, the following information should be documented in the patient’s medical record:

  • Indication for the cesarean delivery or intra-abdominal surgery
  • Indication for the ligation or transection of fallopian tube(s)
  • Detailed description of the procedure, including the steps performed
  • Confirmation of the removal of a portion of the fallopian tube(s) by the laboratory
  • Any complications encountered during the procedure
  • Postoperative care instructions and follow-up plan

7. Billing guidelines

When billing for CPT code 58611, it is important to remember that it is an add-on code and should never take a modifier, as the value of the procedure is set to include only the intraoperative work. Additionally, the code should be reported whether the provider ligates one or both fallopian tubes, as indicated by the “s” in parentheses in the code description.

8. Historical information

CPT 58611 was added to the Current Procedural Terminology system on January 1, 1990. The code was changed on January 1, 2002, and was added to the Medicare Inpatient Only (IPO) list in 2017.

9. Similar codes to CPT 58611

Five similar codes to CPT 58611 and how they differentiate are:

  1. CPT 58600: Ligation or transection of fallopian tube(s), abdominal or vaginal approach, separate procedure. This code is used for a separate procedure, not during cesarean delivery or intra-abdominal surgery.
  2. CPT 58605: Ligation or transection of fallopian tube(s) postpartum, vaginal approach. This code is used for a postpartum procedure with a vaginal approach.
  3. CPT 58615: Occlusion of fallopian tube(s) by device (e.g., band, clip, or Falope ring) at cesarean delivery or intra-abdominal surgery. This code is used when a device is used for occlusion instead of ligation or transection.
  4. CPT 58670: Laparoscopy, surgical, with fulguration of oviducts (with or without transection). This code is used for a laparoscopic approach with fulguration of the oviducts.
  5. CPT 58671: Laparoscopy, surgical, with occlusion of oviducts by device (e.g., band, clip, or Falope ring). This code is used for a laparoscopic approach with occlusion by a device.

10. Examples

Here are 10 detailed examples of CPT code 58611 procedures:

  1. A 35-year-old woman with a history of multiple cesarean deliveries undergoes a cesarean delivery for her fourth child and requests bilateral tubal ligation to prevent future pregnancies.
  2. A 40-year-old woman with a history of hypertension and gestational diabetes undergoes a cesarean delivery and requests bilateral tubal ligation due to the increased risks associated with future pregnancies.
  3. A 32-year-old woman with a history of ectopic pregnancies undergoes a cesarean delivery and requests bilateral tubal ligation to prevent future ectopic pregnancies.
  4. A 38-year-old woman with a history of preterm labor undergoes a cesarean delivery and requests bilateral tubal ligation due to the risks associated with future preterm deliveries.
  5. A 36-year-old woman with a history of placenta previa undergoes a cesarean delivery and requests bilateral tubal ligation due to the risks associated with future pregnancies.
  6. A 34-year-old woman with a history of uterine fibroids undergoes a cesarean delivery and requests bilateral tubal ligation to prevent future pregnancies and associated complications.
  7. A 37-year-old woman with a history of pelvic inflammatory disease undergoes a cesarean delivery and requests bilateral tubal ligation to prevent future pregnancies and associated complications.
  8. A 33-year-old woman with a history of multiple miscarriages undergoes a cesarean delivery and requests bilateral tubal ligation to prevent future pregnancies and associated emotional distress.
  9. A 39-year-old woman with a history of preeclampsia undergoes a cesarean delivery and requests bilateral tubal ligation due to the risks associated with future pregnancies.
  10. A 31-year-old woman with a history of severe endometriosis undergoes a cesarean delivery and requests bilateral tubal ligation to prevent future pregnancies and associated complications.

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