How To Use CPT Code 58291

CPT 58291 describes the procedure for a vaginal hysterectomy with the removal of the uterus, fallopian tubes, and ovaries when the uterus weighs more than 250 grams. 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 58291?

CPT 58291 can be used to describe the surgical procedure of a vaginal hysterectomy with the removal of the uterus, fallopian tubes, and ovaries. This code is specifically used when the weight of the uterus is greater than 250 grams, typically due to the presence of fibroids.

2. Official Description

The official description of CPT code 58291 is: ‘Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s).’ This code is used when the physician surgically removes the uterus, cervix, fallopian tubes, and ovaries using a vaginal approach, specifically when the uterus weighs more than 250 grams.

3. Procedure

1. The patient is placed in the dorsal lithotomy position and given a general anesthetic.
2. The physician 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 physician makes an incision into the cervix or enters the posterior wall to the side of the cervix.
5. The uterosacral and cardinal ligaments are cut close to the cervix, and the uterosacral ligaments are sutured to the posterior vaginal walls for added support.
6. The physician enters the anterior vaginal wall and frees up the bladder.
7. The uterine arteries are clamped and cut, and the infundibulopelvic ligaments are cut to release the ovaries from their attachment to the pelvis.
8. The round ligaments are cut to release the uterus from all its attachments.
9. If the uterus weighs more than 250 grams, it is reduced in size by morcellating it into pieces.
10. The uterus, cervix, fallopian tubes, and ovaries are removed.
11. The vaginal cuff is sutured to the uterosacral and cardinal ligaments to suspend it.
12. The uterosacral ligaments are pleated to prevent prolapse of the small bowel.
13. The vaginal cuff is closed with sutures.

4. Qualifying circumstances

CPT 58291 is used for patients who require a vaginal hysterectomy with the removal of the uterus, fallopian tubes, and ovaries when the uterus weighs more than 250 grams. This procedure is typically performed when there are conditions such as fibroids present, causing the uterus to be larger and heavier than normal. The code is specific to the surgical approach and the weight of the uterus.

5. When to use CPT code 58291

CPT code 58291 should be used when a vaginal hysterectomy is performed with the removal of the uterus, fallopian tubes, and ovaries, and the weight of the uterus is greater than 250 grams. It is important to accurately document the weight of the uterus to support the use of this code.

6. Documentation requirements

To support a claim for CPT code 58291, the following documentation is required:

• Documentation of the patient’s diagnosis and the need for a vaginal hysterectomy
• Record of the weight of the uterus, confirming it is greater than 250 grams
• Date of the procedure
• Details of the surgical approach, including the removal of the fallopian tubes and ovaries
• Any additional procedures or complications encountered during the surgery
• Signature of the performing physician

7. Billing guidelines

When billing for CPT code 58291, ensure that the procedure meets the specific criteria of a vaginal hysterectomy with the removal of the uterus, fallopian tubes, and ovaries, and that the weight of the uterus is greater than 250 grams. It is important to accurately document the weight of the uterus to support the use of this code. Additionally, be aware of any specific guidelines or requirements from insurance providers or payers.

8. Historical information

CPT code 58291 was added to the Current Procedural Terminology system on January 1, 2003. There was a code change on January 1, 2007, where the description was updated to include the removal of tube(s) and/or ovary(s).

9. Examples

1. A patient undergoes a vaginal hysterectomy with the removal of the uterus, fallopian tubes, and ovaries due to the presence of fibroids. The weight of the uterus is documented to be 300 grams.
2. A physician performs a vaginal hysterectomy with the removal of the uterus, fallopian tubes, and ovaries for a patient with a large uterus weighing 280 grams.
3. A woman undergoes a vaginal hysterectomy with the removal of the uterus, fallopian tubes, and ovaries. The weight of the uterus is recorded to be 270 grams.
4. A patient requires a vaginal hysterectomy with the removal of the uterus, fallopian tubes, and ovaries due to the presence of fibroids. The weight of the uterus is documented to be 320 grams.
5. A physician performs a vaginal hysterectomy with the removal of the uterus, fallopian tubes, and ovaries for a patient with a large uterus weighing 290 grams.