How To Use CPT Code 58275

CPT 58275 describes the procedure of vaginal hysterectomy, with total or partial vaginectomy. 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 58275?

CPT 58275 is used to describe a surgical procedure called vaginal hysterectomy, with total or partial vaginectomy. This procedure involves the removal of the uterus and cervix through the vagina, along with the partial or complete excision of the vagina. It is typically performed to treat conditions such as cancer or other diseases affecting the uterus and vagina.

2. Official Description

The official description of CPT code 58275 is: ‘Vaginal hysterectomy, with total or partial vaginectomy.’

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 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 uterosacral and cardinal ligaments close to the cervix are incised, 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 incises the uterine arteries.
7. The broad ligament is elevated to incise the ovarian ligaments and round ligaments, releasing the uterus from all its attachments.
8. The uterus and cervix are removed.
9. For a partial vaginectomy, an incision is made from the top of the vaginal vault in front of the vaginal wall down to the pubocervical fascia. The anterior diseased portion of the vaginal wall is excised along with margins of healthy tissue.
10. For a total vaginectomy, an additional incision is made around the vaginal opening. The diseased portion of the vaginal wall is excised along with margins of healthy tissue. The vaginal cuff is suspended and sutured to the uterosacral and cardinal ligaments to prevent prolapse of the small bowel after surgery.

4. Qualifying circumstances

CPT 58275 is performed on patients who require a vaginal hysterectomy with total or partial vaginectomy. This procedure is typically indicated for conditions such as cancer or other diseases affecting the uterus and vagina. The patient must meet the criteria for undergoing a vaginal hysterectomy and have a medical necessity for the removal of part or all of the vagina.

5. When to use CPT code 58275

CPT code 58275 should be used when a vaginal hysterectomy is performed with the additional procedure of total or partial vaginectomy. It is important to accurately document the extent of the vaginectomy performed to ensure proper coding and billing.

6. Documentation requirements

To support a claim for CPT 58275, the following documentation is required:

• Indication for the vaginal hysterectomy and vaginectomy procedure
• Details of the surgical approach and technique used
• Description of the extent of the vaginectomy performed (total or partial)
• Date of the procedure
• Start and end time of the procedure
• Any additional procedures performed during the same surgical session
• Any complications or unexpected findings
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 58275, ensure that the procedure performed meets the criteria for a vaginal hysterectomy with total or partial vaginectomy. It is important to accurately document the extent of the vaginectomy performed to support proper coding and billing. CPT code 58275 should not be reported with other codes unless additional procedures were performed during the same surgical session.

8. Historical information

CPT code 58275 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition. However, it is important to stay updated with any changes or revisions to the code in future editions of the CPT manual.

9. Examples

1. A patient undergoes a vaginal hysterectomy with total vaginectomy to treat cervical cancer.
2. A patient with uterine prolapse undergoes a vaginal hysterectomy with partial vaginectomy to correct the condition.
3. A patient with a history of vaginal cancer undergoes a vaginal hysterectomy with total vaginectomy as part of their treatment plan.
4. A patient with a large fibroid tumor undergoes a vaginal hysterectomy with partial vaginectomy to remove the tumor and alleviate symptoms.
5. A patient with endometrial cancer undergoes a vaginal hysterectomy with total vaginectomy to remove the cancerous tissue.
6. A patient with a history of vaginal trauma undergoes a vaginal hysterectomy with partial vaginectomy to repair the damage.
7. A patient with a recurrent vaginal prolapse undergoes a vaginal hysterectomy with total vaginectomy to address the issue.
8. A patient with a history of vaginal dysplasia undergoes a vaginal hysterectomy with partial vaginectomy as a preventive measure.
9. A patient with a large uterine fibroid undergoes a vaginal hysterectomy with total vaginectomy to remove the fibroid and alleviate symptoms.
10. A patient with a history of vaginal cancer undergoes a vaginal hysterectomy with partial vaginectomy to remove any remaining cancerous tissue.