How To Use CPT Code 58294

CPT 58294 describes the procedure of vaginal hysterectomy with repair of enterocele for a uterus weighing more than 250 grams. This article will cover the official description, procedure details, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 58294?

CPT 58294 is used to describe a specific surgical procedure known as vaginal hysterectomy with repair of enterocele. This procedure is performed when the uterus weighs more than 250 grams and involves the removal of the uterus and cervix through the vaginal approach. Additionally, the surgeon repairs the enterocele, which is the prolapse of the small bowel into the vaginal canal.

2. Official Description

The official description of CPT code 58294 is: ‘Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele.’

3. Procedure

1. The patient is positioned in the dorsal lithotomy position under general anesthesia.
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 begins the procedure by making an incision either into the cervix or 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 to provide support to the vagina.
6. The surgeon then enters the anterior vaginal wall to free up the bladder.
7. The uterine arteries are clamped and cut, followed by the removal of the uterus from all its attachments, including the ovarian ligaments and round ligaments.
8. If necessary, the size of the uterus is reduced by morcellating it into smaller pieces before removal.
9. An incision is made in the upper vaginal wall where the enterocele is located.
10. The enterocele sac is opened, and the small bowel contents are replaced back into the abdomen.
11. The enterocele sac is sutured closed, and any excess tissue surrounding it is removed.
12. The vaginal cuff may be suspended by suturing it to the uterosacral and cardinal ligaments for additional support to the enterocele repair.
13. Finally, the vaginal cuff is closed with sutures.

4. Qualifying circumstances

CPT 58294 is performed on patients with a uterus weighing more than 250 grams who also have an enterocele. The procedure is indicated when the patient experiences small bowel prolapse into the vaginal canal. The surgeon must carefully assess the patient’s condition and determine the need for vaginal hysterectomy with repair of enterocele.

5. When to use CPT code 58294

CPT code 58294 should be used when performing a vaginal hysterectomy with repair of enterocele for a uterus weighing more than 250 grams. It is important to accurately document the weight of the uterus and the presence of an enterocele to support the use of this code.

6. Documentation requirements

To support a claim for CPT 58294, the following documentation is required:

• Documentation of the patient’s diagnosis and the need for vaginal hysterectomy with repair of enterocele
• Record of the weight of the uterus
• Description of the surgical technique used
• Date of the procedure
• Start and end time of the surgery
• Details of the repair of the enterocele
• Any additional procedures performed during the surgery
• Signature of the surgeon performing the procedure

7. Billing guidelines

When billing for CPT 58294, ensure that the procedure meets the criteria of a vaginal hysterectomy with repair of enterocele for a uterus weighing more than 250 grams. It is important to accurately document the weight of the uterus and the presence of an enterocele to support the use of this code. Additionally, follow any specific billing guidelines provided by the payer to ensure proper reimbursement.

8. Historical information

CPT 58294 was added to the Current Procedural Terminology system on January 1, 2003. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient undergoes vaginal hysterectomy with repair of enterocele for a uterus weighing 300 grams.
2. A surgeon performs vaginal hysterectomy with repair of enterocele for a patient with a large uterus due to the presence of fibroids.
3. A woman with a uterine prolapse undergoes vaginal hysterectomy with repair of enterocele.
4. A patient with a history of small bowel prolapse into the vaginal canal undergoes vaginal hysterectomy with repair of enterocele.
5. A surgeon performs vaginal hysterectomy with repair of enterocele for a patient with a uterine weight of 280 grams.
6. A woman with an enterocele and a uterus weighing 270 grams undergoes vaginal hysterectomy with repair of enterocele.
7. A patient with a large uterus and small bowel prolapse undergoes vaginal hysterectomy with repair of enterocele.
8. A surgeon performs vaginal hysterectomy with repair of enterocele for a patient with a uterine weight of 290 grams.
9. A woman with an enterocele and a uterus weighing 260 grams undergoes vaginal hysterectomy with repair of enterocele.
10. A patient with a history of small bowel prolapse into the vaginal canal undergoes vaginal hysterectomy with repair of enterocele.