How To Use CPT Code 57531

CPT 57531 describes the radical trachelectomy procedure, which involves the surgical removal of the uterine cervix along with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling biopsy. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 57531?

CPT 57531 is a code used to describe the radical trachelectomy procedure. This surgical procedure involves the removal of the uterine cervix, along with the removal of bilateral total pelvic lymph nodes and a biopsy of para-aortic lymph nodes. In some cases, the procedure may also include the removal of the ovaries. It is important to note that this code is specifically for the radical trachelectomy procedure and should not be used for other types of hysterectomies.

2. Official Description

The official description of CPT code 57531 is: ‘Radical trachelectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling biopsy, with or without removal of tube(s), with or without removal of ovary(s).’ It is important to note that for radical abdominal hysterectomy, a different code, 58210, should be used.

3. Procedure

1. The provider preps and drapes the patient for abdominal surgery and administers a general anesthetic.
2. An incision is made in layers until the peritoneal cavity is entered.
3. The provider explores the abdominal and pelvic cavities.
4. The cervix and upper third of the vagina are excised and removed by dissecting the ureters from the parametria.
5. All bleeders are cut, clamped, and sutured, and ligaments keeping the cervix in place are bisected.
6. A bilateral pelvic lymphadenectomy is performed either before or immediately after the radical excision of the cervix.
7. Care is taken not to disturb the infundibulopelvic and tubo-ovarian ligaments, which supply blood to the preserved uterus.
8. A selected para-aortic lymph node sampling is performed.
9. The peritoneal cavity is irrigated, and closed suction drains may be used.
10. The abdomen is closed in layers.

4. Qualifying circumstances

CPT 57531 is performed on patients who require a radical trachelectomy procedure. This procedure is typically indicated for patients with cervical cancer or other conditions that necessitate the removal of the cervix. The procedure may also involve the removal of the ovaries, depending on the specific circumstances. It is important to note that this procedure should only be performed by a qualified healthcare professional with the necessary expertise and training.

5. When to use CPT code 57531

CPT code 57531 should be used when a radical trachelectomy procedure is performed, which involves the removal of the uterine cervix, bilateral total pelvic lymphadenectomy, and para-aortic lymph node sampling biopsy. This code should not be used for other types of hysterectomies or procedures that do not involve the specific components described in the official description.

6. Documentation requirements

To support a claim for CPT code 57531, the healthcare professional must document the following information:

• Patient’s diagnosis necessitating the radical trachelectomy procedure
• Details of the procedure performed, including the removal of the cervix, bilateral total pelvic lymphadenectomy, and para-aortic lymph node sampling biopsy
• Date of the procedure
• Start and end time of the procedure
• Any additional procedures performed, such as the removal of the ovaries
• Any complications or unexpected findings during the procedure
• Signature of the healthcare professional performing the procedure

7. Billing guidelines

When billing for CPT code 57531, it is important to ensure that the procedure performed aligns with the specific components described in the official description. This code should not be reported for other types of hysterectomies or procedures that do not involve the removal of the cervix, bilateral total pelvic lymphadenectomy, and para-aortic lymph node sampling biopsy. It is also important to follow any specific billing guidelines provided by the payer or coding guidelines. Additionally, it is important to accurately document and code any additional procedures performed, such as the removal of the ovaries, if applicable.

8. Historical information

CPT code 57531 was added to the Current Procedural Terminology system on January 1, 1998. Since its addition, there have been no updates or changes to the code.

9. Examples

1. A patient with cervical cancer undergoes a radical trachelectomy procedure, including the removal of the cervix, bilateral total pelvic lymphadenectomy, and para-aortic lymph node sampling biopsy.
2. A healthcare professional performs a radical trachelectomy procedure on a patient with a precancerous condition of the cervix, removing the cervix and performing a bilateral pelvic lymphadenectomy.
3. A patient with a history of cervical dysplasia undergoes a radical trachelectomy procedure to remove the cervix and perform a para-aortic lymph node sampling biopsy.