How To Use CPT Code 58210

CPT 58210 describes the procedure known as radical abdominal hysterectomy, which involves the removal of the uterus and cervix, including the parametrium, through an abdominal incision. 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 58210?

CPT 58210 is a code used to describe the procedure of radical abdominal hysterectomy. This procedure involves the removal of the uterus and cervix, including the parametrium, through an abdominal incision. It may also involve the removal of all or part of the vagina, as well as the pelvic lymph nodes on both sides and a biopsy of the para-aortic lymph nodes. It is important to note that if the procedure includes ovarian transposition, an additional code, 58825, should be used.

2. Official Description

The official description of CPT code 58210 is: ‘Radical abdominal hysterectomy, 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 this code should be used specifically for radical hysterectomy procedures and not for other types of hysterectomies.

3. Procedure

1. The patient is placed in the supine position and administered a general anesthetic.
2. An abdominal incision is made, and the provider explores the abdominal cavity.
3. Washings of the pelvic contents may be taken, and tissue samples may be collected for pathology examination.
4. The provider grasps the top of the uterus and enters the retroperitoneal space, cutting the round ligaments and separating them from the surface of the broad ligament.
5. If the fallopian tubes and ovaries are not being removed, the provider incises them as closely as possible to the uterus. If they are being removed, the infundibulopelvic ligaments are incised instead.
6. The bladder is released from its attachments to the cervix and upper part of the vaginal wall, and the rectum is separated from the vaginal wall.
7. The uterine artery is incised and clamped, and the uterosacral ligaments are incised below the level of the cervix.
8. The ureters are dissected from their place within the cardinal ligaments and freed.
9. The provider removes the top one third of the vagina along with the uterus, cervix, tubes, and ovaries if necessary.
10. Pelvic lymph nodes on both sides are removed, and a biopsy of the para-aortic lymph nodes may be performed.
11. A suprapubic catheter may be inserted to rest the bladder.
12. The vagina is closed where the section was removed, and the peritoneum, muscle, fascia, and abdominal skin incision are closed using sutures.