How To Use CPT Code 58280

CPT 58280 describes the surgical procedure known as vaginal hysterectomy with repair of enterocele. 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 58280?

CPT 58280 is used to describe a surgical procedure called vaginal hysterectomy with repair of enterocele. This procedure involves the removal of the uterus and cervix through the vagina, along with the repair of a small bowel prolapse into the vaginal canal.

2. Official Description

The official description of CPT code 58280 is: ‘Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele.’

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 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 provider removes the uterus and cervix.
9. If necessary, the provider makes an incision in the upper vaginal wall where the enterocele is located, opens the enterocele sac, replaces the small bowel contents back into the abdomen, sutures the enterocele sac closed, and removes any excess tissue surrounding it.
10. For a partial vaginectomy, the provider makes an incision from the top of the vaginal vault in front of the vaginal wall down to the pubocervical fascia, excises the anterior diseased portion of the vaginal wall, and removes margins of healthy tissue.
11. For a total vaginectomy, the provider performs a similar procedure to a partial vaginectomy but makes an additional incision around the vaginal opening, excises the diseased portion of the vaginal wall, removes margins of healthy tissue, suspends the vaginal cuff, pleats the uterosacral ligaments, closes the vaginal cuff, and performs any necessary suturing to close the tissue where the vaginal wall was located.

4. Qualifying circumstances

CPT 58280 is performed on patients who require a vaginal hysterectomy with repair of enterocele. This procedure is typically performed to treat conditions such as uterine prolapse and enterocele. The patient must meet the criteria for undergoing a vaginal hysterectomy and have a small bowel prolapse into the vaginal canal that requires repair.

5. When to use CPT code 58280

CPT code 58280 should be used when a vaginal hysterectomy is performed along with the repair of an enterocele. It is important to accurately document the procedure and ensure that the patient meets the qualifying circumstances for this code.

6. Documentation requirements

To support a claim for CPT code 58280, the following documentation is required:

• Patient’s diagnosis and the need for a vaginal hysterectomy with repair of enterocele
• Details of the procedure performed, including any additional procedures or repairs
• Date of the surgery
• Start and end time of the procedure
• Any complications or unexpected findings during the surgery
• Signature of the provider performing the surgery

7. Billing guidelines

When billing for CPT code 58280, ensure that the procedure performed meets the criteria for a vaginal hysterectomy with repair of enterocele. It is important to follow the specific guidelines and documentation requirements for accurate billing. CPT code 58280 should not be reported with other codes unless additional procedures or repairs are performed during the same surgery.

8. Historical information

CPT code 58280 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 ensure accurate coding and billing.

9. Examples

1. A patient undergoes a vaginal hysterectomy with repair of enterocele to treat uterine prolapse and a small bowel prolapse into the vaginal canal.
2. A provider performs a vaginal hysterectomy with repair of enterocele on a patient with a history of enterocele and uterine prolapse.
3. A patient undergoes a vaginal hysterectomy with repair of enterocele to address symptoms of pelvic organ prolapse.
4. A provider performs a vaginal hysterectomy with repair of enterocele on a patient with a small bowel prolapse and uterine prolapse.
5. A patient undergoes a vaginal hysterectomy with repair of enterocele to alleviate symptoms of pelvic floor dysfunction.
6. A provider performs a vaginal hysterectomy with repair of enterocele on a patient with a small bowel prolapse and significant uterine prolapse.
7. A patient undergoes a vaginal hysterectomy with repair of enterocele to address symptoms of vaginal prolapse and small bowel prolapse.
8. A provider performs a vaginal hysterectomy with repair of enterocele on a patient with a history of uterine prolapse and recurrent enterocele.