How To Use CPT Code 58400

CPT 58400 describes the procedure for uterine suspension, which involves the repositioning of the uterus and the pleating and suturing of stretched ligaments. 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 58400?

CPT 58400 is a code used to describe the procedure of uterine suspension. This procedure involves the repositioning of the uterus and the pleating and suturing of stretched ligaments that hold the uterus in place. It is performed to address uterine prolapse, where the uterus sags or slips from its normal position.

2. Official Description

The official description of CPT code 58400 is: ‘Uterine suspension, with or without shortening of round ligaments, with or without shortening of sacrouterine ligaments; (separate procedure).’ This code is used when the provider performs a procedure to suspend the uterus and may involve the shortening of round ligaments and/or sacrouterine ligaments.

3. Procedure

1. The patient is placed in the supine position and administered a general anesthetic.
2. The provider makes a low transverse abdominal incision or an incision in the vagina to access the uterus and ligaments.
3. The provider identifies and exposes the round and sacrouterine ligaments.
4. Various methods are used to shorten the ligaments, such as Gillian suspension, Olshausen operation, or Baldy Webster procedure.
5. In the Olshausen operation, the provider sutures the round ligaments to the abdominal fascia.
6. In a Gillian suspension, the provider brings each round ligament below the anterior rectus sheath.
7. In the Baldy Webster procedure, the provider passes the round ligaments through the anterior and posterior broad ligaments and sutures them to the posterior surface of the uterus.
8. The provider may also fold and tack the sacrouterine ligaments to shorten them.
9. The abdomen is closed with sutures.

4. Qualifying circumstances

CPT 58400 is performed for patients with uterine prolapse, where the uterus sags or slips from its normal position. The procedure involves the suspension of the uterus and may include the shortening of round ligaments and/or sacrouterine ligaments. It is important to note that this is a separate procedure and should not be reported if performed as part of another procedure.

5. When to use CPT code 58400

CPT code 58400 should be used when the provider performs a separate procedure for uterine suspension. It is appropriate when the uterus needs to be repositioned and the stretched ligaments need to be pleated and sutured. This code should not be used if the procedure is performed as part of another procedure.

6. Documentation requirements

To support a claim for CPT 58400, the provider must document the following information:

• Patient’s diagnosis of uterine prolapse
• Details of the procedure performed, including the approach (abdominal or vaginal)
• Specific ligaments addressed (round ligaments and/or sacrouterine ligaments)
• Method used to shorten the ligaments
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the provider

7. Billing guidelines

When billing for CPT 58400, ensure that the procedure meets the criteria for uterine suspension and is performed as a separate procedure. It is important to note that this code should not be reported if performed as part of another procedure. If the procedure is performed laparoscopically, report the unlisted code 58578 and use CPT code 58400 as a comparison code to indicate the level of physician work involved.

8. Historical information

CPT code 58400 was added to the Current Procedural Terminology system on January 1, 1990. The code has not undergone any updates since its addition. In 2017, it was added to the Inpatient Only (IPO) list for Medicare.

9. Examples

1. A provider performs a uterine suspension procedure on a patient with uterine prolapse, repositioning the uterus and pleating and suturing the round ligaments.
2. During a separate procedure, a provider performs a uterine suspension, shortening both the round and sacrouterine ligaments to address uterine prolapse.
3. A patient undergoes a uterine suspension procedure, with the provider utilizing the Olshausen operation to suture the round ligaments to the abdominal fascia.
4. A provider performs a uterine suspension, utilizing the Baldy Webster procedure to pass the round ligaments through the broad ligaments and suture them to the posterior surface of the uterus.
5. During a uterine suspension procedure, the provider folds and tacks the sacrouterine ligaments to shorten them and reposition the uterus.
6. A patient with uterine prolapse undergoes a uterine suspension procedure, with the provider utilizing the Gillian suspension method to bring each round ligament below the anterior rectus sheath.
7. A provider performs a uterine suspension procedure, shortening the round ligaments and addressing uterine prolapse in a patient.
8. During a separate procedure, the provider performs a uterine suspension, pleating and suturing the sacrouterine ligaments to reposition the uterus.