How To Use CPT Code 58263

CPT 58263 describes the procedure for a vaginal hysterectomy with removal of tube(s) and/or ovary(s), along with repair of an enterocele, for a uterus weighing 250 grams or less. 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 58263?

CPT 58263 is used to describe a specific surgical procedure known as a vaginal hysterectomy. This procedure involves the removal of the uterus, cervix, fallopian tubes, and ovaries using a vaginal approach. Additionally, the provider performs a repair of an enterocele, which is a condition where the small bowel prolapses into the vaginal canal. This code is specifically used when the weight of the uterus is 250 grams or less.

2. Official Description

The official description of CPT code 58263 is: ‘Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele.’

3. Procedure

1. The patient is positioned in the dorsal lithotomy position and administered a general anesthetic.
2. The provider examines the genital tract for any abnormalities before beginning the surgery.
3. A weighted speculum is inserted into the vagina, and a numbing agent is injected into the cervix and surrounding tissue.
4. The provider makes an incision into the cervix or enters the posterior wall at the side of the cervix to start the procedure.
5. The uterosacral and cardinal ligaments are incised close to the cervix, and the uterosacral ligaments are sutured to the posterior vaginal walls for added support.
6. The provider enters the anterior vaginal wall to free up the bladder and clamps and cuts the uterine arteries.
7. The broad ligament is elevated to cut the infundibulopelvic ligaments, releasing the ovaries from their attachment to the pelvis, and the round ligaments, releasing the uterus from all of its attachments.
8. The provider removes the uterus, cervix, fallopian tubes, and ovaries, ensuring that the weight of the uterus is 250 grams or less.
9. An incision is made in the upper vaginal wall to locate the enterocele, and the small bowel contents are returned to the abdomen.
10. The enterocele sac is closed with sutures, and any excess tissue surrounding it is removed.
11. The vaginal cuff may be suspended and pleated for additional support to the enterocele repair, and it is closed with sutures.

4. Qualifying circumstances

CPT 58263 is performed on patients who require a vaginal hysterectomy with removal of tube(s) and/or ovary(s), along with repair of an enterocele. The weight of the uterus must be 250 grams or less. This procedure is typically performed by a qualified healthcare professional in cases where the patient has an enterocele and requires removal of the uterus, fallopian tubes, and/or ovaries.

5. When to use CPT code 58263

CPT code 58263 should be used when a vaginal hysterectomy is performed with removal of tube(s) and/or ovary(s), along with repair of an enterocele, and the weight of the uterus is 250 grams or less. It is important to accurately document the weight of the uterus to ensure proper coding and billing.

6. Documentation requirements

To support a claim for CPT code 58263, the healthcare professional must document the following information:

• Weight of the uterus (250 grams or less)
• Details of the procedure performed, including removal of tube(s) and/or ovary(s) and repair of an enterocele
• Date of the surgery
• Any additional findings or procedures performed during the surgery
• Signature of the healthcare professional performing the procedure

7. Billing guidelines

When billing for CPT code 58263, ensure that the procedure meets the specific criteria outlined in the code description. It is important to accurately document the weight of the uterus and any additional procedures performed. CPT code 58263 should not be reported with other codes unless additional procedures are performed that meet the criteria for separate reporting. Follow the appropriate coding and billing guidelines provided by the payer to ensure accurate reimbursement.

8. Historical information

CPT code 58263 was added to the Current Procedural Terminology system on January 1, 1993. There have been two code changes since its addition, with the most recent change occurring on January 1, 2007. The code description was modified to specify the weight of the uterus (250 grams or less) and the inclusion of repair of an enterocele.

9. Examples

1. A patient undergoes a vaginal hysterectomy with removal of both fallopian tubes and repair of an enterocele. The weight of the uterus is 200 grams.
2. A provider performs a vaginal hysterectomy with removal of one ovary and repair of an enterocele. The weight of the uterus is 180 grams.
3. A patient requires a vaginal hysterectomy with removal of both fallopian tubes and ovaries, along with repair of an enterocele. The weight of the uterus is 220 grams.