How To Use CPT Code 0404T

CPT 0404T describes a procedure called transcervical uterine fibroid ablation with ultrasound guidance and radiofrequency. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples.

1. What is CPT Code 0404T?

CPT 0404T can be used to report a specific procedure known as transcervical uterine fibroid ablation with ultrasound guidance and radiofrequency. This code is used when a provider uses radiofrequency waves to destroy abnormal or diseased tissue in the uterus, specifically fibroids. The procedure is performed through the cervix with the guidance of ultrasound imaging.

2. Official Description

The official description of CPT code 0404T is: ‘Transcervical uterine fibroid(s) ablation with ultrasound guidance, radiofrequency.’

3. Procedure

1. The patient is positioned in the lithotomy position, lying on her back with knees bent and positioned above the hips.
2. The provider inserts a probe through the cervix, which contains a radiofrequency energy source and an ultrasound device.
3. Using ultrasound guidance, the provider identifies one or more uterine fibroids and inserts the radiofrequency device into them.
4. The radiofrequency device is heated to the desired temperature and applied to the center of the fibroid for a few minutes, destroying the fibroid tissue.
5. The provider also cauterizes the puncture site in the uterine wall using the radiofrequency device.
6. Multiple fibroids may be treated during the procedure.
7. Once the procedure is complete, the provider removes the probe.

4. Qualifying circumstances

CPT 0404T is used for patients who require transcervical uterine fibroid ablation with ultrasound guidance and radiofrequency. This procedure is typically performed for the treatment of uterine fibroids, which are benign tumors arising from fibrous or connective tissue in the uterus.

5. When to use CPT code 0404T

CPT code 0404T should be used when a provider performs transcervical uterine fibroid ablation with ultrasound guidance and radiofrequency. It is important to note that coverage for this procedure may vary among payers, so it is recommended to check with Medicare or other payers for their specific policies.

6. Documentation requirements

To support a claim for CPT code 0404T, the provider must document the following information:

• Patient’s diagnosis and the medical necessity for the procedure
• Description of the procedure performed, including the use of ultrasound guidance and radiofrequency
• Date of the procedure
• Duration of the procedure
• Number and location of fibroids treated
• Any complications or additional procedures performed
• Signature of the provider

7. Billing guidelines

When billing for CPT code 0404T, ensure that the procedure meets the specific criteria outlined in the code description. It is important to note that coverage for this procedure may vary among payers, so it is recommended to check with Medicare or other payers for their specific policies. Additionally, it is important to follow any additional guidelines or requirements set forth by the payer.

8. Historical information

CPT code 0404T was added to the Current Procedural Terminology system on January 1, 2016. There have been no updates to the code since its addition.

9. Examples

1. A provider performs transcervical uterine fibroid ablation with ultrasound guidance and radiofrequency to treat multiple fibroids in a patient.
2. During the procedure, the provider uses radiofrequency waves to destroy a large uterine fibroid under ultrasound guidance.
3. A patient undergoes transcervical uterine fibroid ablation with ultrasound guidance and radiofrequency to treat a single fibroid.
4. A provider performs the procedure to treat multiple uterine fibroids in a patient with a history of heavy menstrual bleeding.
5. During the procedure, the provider uses ultrasound guidance to precisely target and destroy a small uterine fibroid using radiofrequency waves.
6. A patient with symptomatic uterine fibroids undergoes transcervical uterine fibroid ablation with ultrasound guidance and radiofrequency.
7. The provider performs the procedure to treat a large uterine fibroid causing pelvic pain and pressure in a patient.
8. A provider uses radiofrequency waves under ultrasound guidance to ablate multiple uterine fibroids in a patient with infertility issues.
9. During the procedure, the provider successfully treats a large uterine fibroid using transcervical uterine fibroid ablation with ultrasound guidance and radiofrequency.
10. A patient with recurrent uterine fibroids undergoes the procedure to prevent further growth and symptoms.