How To Use CPT Code 58152

CPT 58152 describes the procedure for a total abdominal hysterectomy with or without removal of the fallopian tubes and ovaries, along with a colpo-urethrocystopexy. 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 58152?

CPT 58152 can be used to describe the surgical procedure for a total abdominal hysterectomy, which involves the removal of the uterus and cervix through an abdominal incision. This code may also include the removal of the fallopian tubes and ovaries, either partially or completely. Additionally, it includes a colpo-urethrocystopexy, which is the suspension of the urethra to supporting structures using sutures.

2. Official Description

The official description of CPT code 58152 is: ‘Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); with colpo-urethrocystopexy (eg, Marshall-Marchetti-Krantz, Burch).’

3. Procedure

1. The patient is positioned in the supine position and administered a general anesthetic.
2. An abdominal incision is made, typically in the midline, to access the abdominal cavity.
3. The provider explores the abdominal cavity and identifies the uterus, fallopian tubes, ovaries, and supporting ligaments.
4. The provider cuts the round ligaments and separates them from the surface of the broad ligament.
5. If the fallopian tubes and ovaries are not being removed, the provider cuts them as closely as possible to the uterus. If they are being removed, the provider cuts the infundibulopelvic ligaments instead.
6. The provider releases the bladder from its attachment to the cervix.
7. The provider identifies and cuts the uterine artery, clamping and suturing it as necessary.
8. The provider then cuts, clamps, and suture-ligates the cardinal ligament and uterosacral ligament, anchoring them to provide support.
9. A circular incision is made into the vagina, and the uterus, cervix, fallopian tubes, and ovaries (if removed) are removed in one piece.
10. The provider performs a colpo-urethrocystopexy, either using the Marshall-Marchetti-Krantz (MMK) or Burch technique.
11. The vaginal cuff is closed with sutures and attached to the uterosacral ligaments to prevent prolapse.
12. The peritoneum, muscle, fascia, and abdominal skin incision are closed with sutures.

4. Qualifying circumstances

CPT 58152 is performed on patients who require a total abdominal hysterectomy, with or without removal of the fallopian tubes and ovaries, and who also have stress urinary incontinence. The colpo-urethrocystopexy is performed to provide support to the urethra and address the incontinence. The procedure is typically performed by a gynecologist or a surgeon with expertise in gynecological surgeries.

5. When to use CPT code 58152

CPT code 58152 should be used when a total abdominal hysterectomy is performed, with or without removal of the fallopian tubes and ovaries, along with a colpo-urethrocystopexy. It is important to accurately document the specific procedures performed during the surgery to support the use of this code.

6. Documentation requirements

To support a claim for CPT 58152, the following documentation is required:

• Indication for the total abdominal hysterectomy
• Documentation of the removal or non-removal of the fallopian tubes and ovaries
• Description of the colpo-urethrocystopexy technique used (e.g., Marshall-Marchetti-Krantz, Burch)
• Date of the procedure
• Details of the surgical approach and technique
• Any additional procedures performed during the surgery
• Signature of the performing surgeon

7. Billing guidelines

When billing for CPT 58152, it is important to ensure that the documentation supports the performance of a total abdominal hysterectomy with or without removal of the fallopian tubes and ovaries, along with a colpo-urethrocystopexy. Modifier 22 may be appended if the procedure required significant additional work due to complications or other factors. It is also important to follow any specific billing guidelines provided by the payer or Medicare.

8. Historical information

CPT 58152 was added to the Current Procedural Terminology system on January 1, 1990. The code has not undergone any updates since its addition. In 2017, it was added to the Inpatient Only (IPO) list for Medicare.

9. Examples

1. A patient undergoes a total abdominal hysterectomy with removal of the fallopian tubes and ovaries, along with a colpo-urethrocystopexy using the Marshall-Marchetti-Krantz technique.
2. A gynecological surgeon performs a total abdominal hysterectomy with preservation of the fallopian tubes and ovaries, along with a colpo-urethrocystopexy using the Burch technique.