How To Use CPT Code 58180

CPT 58180 describes the procedure known as supracervical abdominal hysterectomy, which involves the removal of the uterus through an abdominal incision. This article will provide an overview of CPT code 58180, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 58180?

CPT 58180 is used to describe the supracervical abdominal hysterectomy procedure. This procedure involves the removal of the uterus through an abdominal incision, and it may also include the removal of the fallopian tubes and ovaries. It is important to note that this code specifically refers to the subtotal hysterectomy, where the cervix is left intact.

2. Official Description

The official description of CPT code 58180 is: ‘Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s).’ This code encompasses the removal of the uterus through an abdominal incision, with the option of removing the fallopian tubes and ovaries.

3. Procedure

1. The patient is positioned in the supine position and administered a general anesthetic.
2. The surgeon makes a midline incision into the abdominal wall to access the abdominal cavity.
3. The surgeon grasps the top of the uterus with a clamp and enters the retroperitoneal space.
4. The round ligaments are cut, and the surgeon separates them from the surface of the broad ligament.
5. The incision is extended along the broad ligament to loosen the area around the uterus.
6. The surgeon locates and moves the ureters away from the uterus.
7. If the fallopian tubes and ovaries are not being removed, the surgeon cuts the fallopian tubes and ovarian ligaments close to the uterus.
8. If the fallopian tubes and ovaries are being removed, the surgeon cuts the infundibulopelvic ligaments instead.
9. The surgeon releases the bladder from its attachment to the cervix.
10. The uterine artery is identified, cut, and clamped.
11. The surgeon separates the fundus of the uterus from the cervix using a scalpel.
12. The uterus is removed from the abdominal cavity.
13. If necessary, the surgeon may core out a part of the cervical canal to prevent cancer.
14. The top of the exposed cervix is closed with sutures.
15. The peritoneum, muscle, fascia, and abdominal skin incision are closed with sutures.

4. Qualifying circumstances

CPT 58180 is performed on patients who require a supracervical abdominal hysterectomy. This procedure may be necessary for various reasons, such as the presence of uterine fibroids, abnormal uterine bleeding, or other conditions that warrant the removal of the uterus. The decision to remove the fallopian tubes and ovaries may depend on the patient’s specific circumstances and the surgeon’s judgment.

5. When to use CPT code 58180

CPT code 58180 should be used when a supracervical abdominal hysterectomy is performed, with or without the removal of the fallopian tubes and ovaries. It is important to accurately document the details of the procedure to support the use of this code.

6. Documentation requirements

To support a claim for CPT code 58180, the following documentation is required:

• Patient’s diagnosis and the medical necessity for the supracervical abdominal hysterectomy
• Details of the procedure, including whether the fallopian tubes and ovaries were removed
• Date of the procedure
• Start and end time of the procedure
• Any additional procedures or services performed during the same operative session
• Signature of the performing surgeon

7. Billing guidelines

When billing for CPT code 58180, it is important to ensure that the procedure performed aligns with the code description. Additionally, it is crucial to follow any specific billing guidelines provided by the payer. It is also important to note that CPT code 58180 should not be reported with other codes that describe the removal of the cervix or total hysterectomy procedures.

8. Historical information

CPT code 58180 was added to the Current Procedural Terminology system on January 1, 1990. The code has not undergone any updates since its addition. However, it is worth noting that Medicare added this procedure to its Inpatient Only (IPO) list in 2017, indicating that it is typically performed on an inpatient basis.

9. Examples

1. A patient with uterine fibroids undergoes a supracervical abdominal hysterectomy without the removal of the fallopian tubes and ovaries.
2. A patient with abnormal uterine bleeding undergoes a supracervical abdominal hysterectomy with the removal of the fallopian tubes and ovaries.
3. A patient with a history of endometriosis undergoes a supracervical abdominal hysterectomy without the removal of the fallopian tubes and ovaries.
4. A patient with adenomyosis undergoes a supracervical abdominal hysterectomy with the removal of the fallopian tubes and ovaries.
5. A patient with uterine prolapse undergoes a supracervical abdominal hysterectomy without the removal of the fallopian tubes and ovaries.