How To Use CPT Code 58290

CPT 58290 describes the surgical procedure known as vaginal hysterectomy for a uterus that weighs more than 250 grams. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 58290?

CPT 58290 is used to describe a surgical procedure called vaginal hysterectomy. This procedure is performed when the uterus weighs more than 250 grams, typically due to the presence of fibroids. The surgeon removes the uterus and cervix using a vaginal approach, without making any abdominal incisions.

2. Official Description

The official description of CPT code 58290 is: ‘Vaginal hysterectomy, for uterus greater than 250 g.’

3. Procedure

1. The patient is positioned in the dorsal lithotomy position and given a general anesthetic.
2. The surgeon 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 surgeon makes an incision either into the cervix or the posterior wall to the side of the cervix.
5. The uterosacral and cardinal ligaments close to the cervix are cut, and the uterosacral ligaments are sutured to the posterior vaginal walls for added support.
6. The surgeon enters the anterior vaginal wall to free up the bladder.
7. The uterine arteries are clamped and cut, and the surgeon moves up the broad ligament to cut the ovarian ligaments and round ligaments, releasing the uterus from all its attachments.
8. If the uterus is larger than 250 grams, it is reduced in size by morcellating it into pieces.
9. The uterus and cervix are removed, and the vaginal cuff is sutured to the uterosacral and cardinal ligaments.
10. The uterosacral ligaments are pleated to prevent prolapse of the small bowel, and the vaginal cuff is closed with sutures.

4. Qualifying circumstances

CPT 58290 is performed on patients whose uterus weighs more than 250 grams, typically due to the presence of fibroids. The procedure is appropriate for patients who do not require abdominal incisions and can undergo surgery through the vaginal approach. It is important to note that the weight of the uterus should be confirmed through pathology reports, and additional procedures may be performed if the surgeon removes the tubes and ovaries.

5. When to use CPT code 58290

CPT code 58290 should be used when performing a vaginal hysterectomy for a uterus that weighs more than 250 grams. It is important to ensure that the procedure is performed solely through the vaginal approach and does not involve any abdominal incisions.

6. Documentation requirements

To support a claim for CPT 58290, the following documentation is required:

• Confirmation of the uterus weight through pathology reports
• Description of the surgical approach used (vaginal approach without abdominal incisions)
• Details of any additional procedures performed, if applicable
• Any complications or unexpected findings during the surgery
• Signature of the surgeon performing the procedure

7. Billing guidelines

When billing for CPT 58290, ensure that the procedure meets the qualifying circumstances and is performed solely through the vaginal approach. It is important to check the documentation for any additional procedures performed, as they may require separate coding. Pathology reports should be used to confirm the weight of the uterus.

8. Historical information

CPT 58290 was added to the Current Procedural Terminology system on January 1, 2003. There have been two code changes since its addition, with the most recent change occurring on January 1, 2010.

9. Examples

1. A patient undergoes a vaginal hysterectomy for a uterus weighing 300 grams due to the presence of fibroids.
2. A surgeon performs a vaginal hysterectomy for a patient with a uterus weighing 280 grams, removing the uterus and cervix through the vaginal approach.
3. During a vaginal hysterectomy, the surgeon reduces the size of a uterus weighing 270 grams by morcellating it into pieces before removing it.
4. A patient with a uterus weighing 260 grams undergoes a vaginal hysterectomy without any abdominal incisions.
5. A surgeon performs a vaginal hysterectomy for a patient with a uterus weighing 290 grams, suturing the vaginal cuff to the uterosacral and cardinal ligaments after removal.
6. During a vaginal hysterectomy, the surgeon cuts the uterosacral and cardinal ligaments close to the cervix for a patient with a uterus weighing 275 grams.
7. A patient undergoes a vaginal hysterectomy for a uterus weighing 255 grams, with the surgeon pleating the uterosacral ligaments to prevent prolapse of the small bowel.
8. A surgeon performs a vaginal hysterectomy for a patient with a uterus weighing 310 grams, closing the vaginal cuff with sutures after removal.
9. During a vaginal hysterectomy, the surgeon clamps and cuts the uterine arteries for a patient with a uterus weighing 290 grams.
10. A patient undergoes a vaginal hysterectomy for a uterus weighing 275 grams, with the surgeon examining the genital tract for any abnormalities before starting the surgery.