How To Use CPT Code 58270

CPT 58270 describes the procedure of vaginal hysterectomy with repair of 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 58270?

CPT 58270 is used to describe a surgical procedure known as vaginal hysterectomy with repair of enterocele. This procedure involves the removal of the uterus and cervix through the vagina, and the repair of a small bowel prolapse into the vaginal canal. It is specifically used for cases where the uterus weighs 250 grams or less.

2. Official Description

The official description of CPT code 58270 is: ‘Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele.’ This code should be used when performing a vaginal hysterectomy and repairing an enterocele in a patient with a uterus weighing 250 grams or less. It is important to note that if the procedure involves the removal of tubes and/or ovaries along with the repair of enterocele, a different code (58263) should be used.

3. Procedure

1. The patient is positioned in the dorsal lithotomy position and given a general anesthetic.
2. The provider examines the genital tract for any abnormalities before starting 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 begin the procedure.
5. The provider incises the uterosacral and cardinal ligaments close to the cervix and sutures the uterosacral ligaments to the posterior vaginal walls for added support.
6. The provider enters the anterior vaginal wall to free up the bladder and clamps and incises the uterine arteries.
7. The provider elevates the broad ligament to incise the ovarian ligaments and round ligaments, releasing the uterus from all its attachments.
8. The uterus and cervix are removed, and an incision is made in the upper vaginal wall where the enterocele is located.
9. The provider opens the enterocele sac, replaces the small bowel contents back into the abdomen, and sutures the enterocele sac closed.
10. If necessary, the provider may suspend the vaginal cuff by suturing it to the uterosacral and cardinal ligaments and pleat the uterosacral ligaments for additional support.
11. The provider closes the vaginal cuff with sutures to complete the procedure.

4. Qualifying circumstances

CPT 58270 is performed on patients who require a vaginal hysterectomy and have a uterus weighing 250 grams or less. The procedure also involves the repair of an enterocele, which is a bulging of the small intestines and peritoneum into the vaginal canal. It is important to note that if the procedure includes the removal of tubes and/or ovaries, a different code (58263) should be used.

5. When to use CPT code 58270

CPT code 58270 should be used when performing a vaginal hysterectomy with repair of enterocele for a patient with a uterus weighing 250 grams or less. It is important to ensure that the procedure meets the specific criteria outlined in the code description.

6. Documentation requirements

To support a claim for CPT code 58270, the following documentation is required:

• Patient’s diagnosis and indication for the procedure
• Details of the procedure performed, including the removal of the uterus and repair of the enterocele
• Documentation of the weight of the uterus
• Date of the procedure
• Any additional procedures or repairs performed during the same session
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 58270, it is important to ensure that the procedure meets the specific criteria outlined in the code description. The procedure should only be reported if the patient’s uterus weighs 250 grams or less and if the repair of enterocele is performed. It is also important to follow any additional guidelines provided by the payer or coding guidelines.

8. Historical information

CPT code 58270 was added to the Current Procedural Terminology system on January 1, 1990. 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 that the procedure is for a uterus weighing 250 grams or less.

9. Examples

1. A patient undergoes a vaginal hysterectomy with repair of enterocele for a uterus weighing 200 grams.
2. A provider performs a vaginal hysterectomy with repair of enterocele for a patient with a uterus weighing 240 grams.
3. A patient with a uterus weighing 220 grams undergoes a vaginal hysterectomy with repair of enterocele.
4. A provider performs a vaginal hysterectomy with repair of enterocele for a patient with a uterus weighing 230 grams.
5. A patient undergoes a vaginal hysterectomy with repair of enterocele for a uterus weighing 250 grams.
6. A provider performs a vaginal hysterectomy with repair of enterocele for a patient with a uterus weighing 210 grams.
7. A patient with a uterus weighing 240 grams undergoes a vaginal hysterectomy with repair of enterocele.