How To Use CPT Code 58146
CPT 58146 describes the excision of fibroid tumors of the uterus through an abdominal approach. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.
1. What is CPT Code 58146?
CPT 58146 can be used to describe the excision of 5 or more fibroid tumors of the uterus through an abdominal approach. The total weight of the tumors must be greater than 250 g. This code is used when the physician removes multiple fibroid tumors from the uterus using an abdominal incision.
2. Official Description
The official description of CPT code 58146 is: ‘Myomectomy, excision of fibroid tumor(s) of uterus, 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 g, abdominal approach.’
3. Procedure
- The physician administers a general anesthetic and positions the patient in the supine position.
- An abdominal incision is made to expose the uterus.
- The physician identifies the location of the fibroid tumors within the myometrium of the uterus.
- The physician excises each fibroid tumor, suturing any defects in the outside of the uterus caused by the removal.
- Bleeding is controlled, and the abdominal incision is closed with sutures.
4. Qualifying circumstances
CPT 58146 is used when the physician removes 5 or more fibroid tumors of the uterus through an abdominal approach. The total weight of the tumors must be greater than 250 g. This procedure is typically performed on patients with intramural myomas, which are tumors that develop within the uterine wall.
5. When to use CPT code 58146
CPT code 58146 should be used when the physician removes 5 or more fibroid tumors of the uterus through an abdominal approach. It should not be reported if other codes, such as 58140-58145 or 58150-58240, have already been used for the same procedure.
6. Documentation requirements
To support a claim for CPT 58146, the physician must document the following information:
- Presence of intramural fibroids
- Number of fibroids removed (5 or more)
- Total weight of the fibroids
- Details of the abdominal approach
- Date of the procedure
- Signature of the physician performing the procedure
7. Billing guidelines
When billing for CPT 58146, ensure that the procedure meets the qualifying circumstances, including the removal of 5 or more fibroid tumors with a total weight greater than 250 g through an abdominal approach. It should not be reported if other codes for the same procedure have already been used. Follow any additional guidelines provided by the payer or coding guidelines.
8. Historical information
CPT 58146 was added to the Current Procedural Terminology system on January 1, 2003. There have been no updates to the code since its addition. It was also added to the Inpatient Only (IPO) list for Medicare in 2017.
9. Examples
- A physician performing an abdominal myomectomy to remove 7 fibroid tumors with a total weight of 300 g from a patient’s uterus.
- A surgeon excising 6 intramural fibroids weighing 280 g in total through an abdominal approach.
- A gynecologist removing 5 fibroid tumors with a combined weight of 270 g from a patient’s uterus using an abdominal incision.
- An obstetrician performing an abdominal myomectomy to excise 8 intramural fibroids weighing 320 g in total.
- A physician removing 9 fibroid tumors with a total weight of 350 g from a patient’s uterus through an abdominal approach.
- A surgeon excising 5 intramural fibroids weighing 260 g in total using an abdominal incision.
- A gynecologist performing an abdominal myomectomy to remove 6 fibroid tumors with a combined weight of 290 g from a patient’s uterus.
- An obstetrician removing 7 intramural fibroids weighing 310 g in total through an abdominal approach.
- A physician excising 5 fibroid tumors with a total weight of 280 g from a patient’s uterus using an abdominal incision.
- A surgeon performing an abdominal myomectomy to remove 8 intramural fibroids weighing 330 g in total.
