How To Use CPT Code 58145

CPT 58145 describes the excision of fibroid tumor(s) of the uterus, specifically 1 to 4 intramural myomas with a total weight of 250 g or less and/or removal of surface myomas using a vaginal approach. 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 58145?

CPT 58145 is used to describe the surgical procedure of removing fibroid tumor(s) from the uterus. Specifically, this code applies to the excision of 1 to 4 intramural myomas with a total weight of 250 g or less and/or the removal of surface myomas. The procedure is performed using a vaginal approach, which involves accessing the uterus through the vagina.

2. Official Description

The official description of CPT code 58145 is: ‘Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or removal of surface myomas; vaginal approach.’

3. Procedure

1. The patient is positioned in lithotomy position and given a general anesthetic.
2. A weighted speculum is inserted into the vagina, and the cervix is grasped with a tenaculum.
3. The prolapsing fibroid is grasped with a clamp and brought out of the cervix.
4. The fibroid is either twisted to break the stalk from the uterine wall or cut around the stalk using a wire loop electrode.
5. A metal or plastic vaginal speculum is inserted to keep the vaginal opening open and separate the vaginal wall.
6. The vaginal mucosa is cut, and the endopelvic fascia is separated to expose the peritoneum.
7. The vesicouterine space is dissected to identify the uterine wall.
8. The uterine wall is cut to the level of the fibroids.
9. The 1 to 4 intramural myomas with a total weight of 250 g or less are excised.
10. If present, surface myomas are also removed.
11. The uterine wall is closed with sutures, and all instruments are withdrawn.

4. Qualifying circumstances

CPT 58145 is performed on patients who have 1 to 4 intramural myomas with a total weight of 250 g or less and/or surface myomas that require surgical removal. The procedure is done using a vaginal approach, which involves accessing the uterus through the vagina. It is important to note that this code does not specify a particular number of surface myomas, as they tend to be small and easily removed. The code also applies to the removal of surface benign neoplasms of muscular tissue.

5. When to use CPT code 58145

CPT code 58145 should be used when a patient requires the excision of 1 to 4 intramural myomas with a total weight of 250 g or less and/or removal of surface myomas. The procedure is performed using a vaginal approach, accessing the uterus through the vagina. It is important to ensure that the patient meets the specific criteria outlined in the code description before using CPT 58145.

6. Documentation requirements

To support a claim for CPT 58145, the following documentation is required:

• Patient’s diagnosis indicating the presence of 1 to 4 intramural myomas and/or surface myomas
• Description of the surgical procedure performed, including the use of a vaginal approach
• Date of the procedure
• Start and end time of the procedure
• Details of the specific fibroids removed, including their location and weight
• Any additional procedures performed, such as hysteroscopy
• Any complications or unexpected findings
• Signature of the performing physician

7. Billing guidelines

When billing for CPT 58145, ensure that the procedure meets the specific criteria outlined in the code description. It is important to accurately document the number of intramural myomas and their total weight, as well as any surface myomas removed. CPT 58145 should not be reported with other codes unless additional procedures, such as hysteroscopy, are performed. It is also important to note that if the total weight of all removed fibroids is less than 250 grams, CPT 58145 should be reported. For procedures performed using an abdominal approach, refer to CPT code 58140. For the excision of 5 or more intramural myomas and/or intramural myomas weighing greater than 250 g using an abdominal approach, refer to CPT code 58146.

8. Historical information

CPT code 58145 was added to the Current Procedural Terminology system on January 1, 1990. Since its addition, there have been several changes to the code description, including updates to the terminology used and the specific criteria for reporting the procedure.

9. Examples

1. A patient undergoes a myomectomy using a vaginal approach to remove 2 intramural myomas with a total weight of 150 g.
2. A physician performs a surgical procedure to excise 3 intramural myomas and remove 1 surface myoma using a vaginal approach.