How To Use CPT Code 58540

CPT 58540 describes the repair of a uterine anomaly known as Strassman type hysteroplasty. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 58540?

CPT 58540 is used to report the repair of a specific uterine anomaly called Strassman type hysteroplasty. This procedure involves correcting a uterus with two horns to create a single uterine cavity. It is performed via an abdominal approach and can be quite extensive depending on the extent of the repair needed.

2. Official Description

The official description of CPT code 58540 is: ‘Hysteroplasty, repair of uterine anomaly (Strassman type).’ This code is used when the provider corrects a uterine anomaly, specifically the Strassman type, to create a single uterine cavity.

3. Procedure

1. The provider administers a general anesthetic and positions the patient in a supine position.
2. A Pfannenstiel incision is made just above the mons pubis to access the uterus.
3. A transverse incision is made across the top of the uterus from one uterine horn to the other.
4. A hemostatic solution is injected at the incision site to minimize blood loss.
5. The front and back parts of the incision are sutured to themselves, connecting the tissue and creating one long uterine incision and cavity.
6. The provider sutures the now single incision closed in layers and closes the abdominal incision.

4. Qualifying circumstances

CPT 58540 is performed to correct a specific uterine anomaly known as the Strassman type. This procedure is indicated when a patient has a uterus with two horns that need to be repaired to create a single uterine cavity. It is important to note that this code should not be used for the closure of a vesicouterine fistula, which has its own specific code (51920).

5. When to use CPT code 58540

CPT code 58540 should be used when the provider performs a hysteroplasty to repair a uterine anomaly of the Strassman type. It is important to accurately document the specific type of uterine anomaly being repaired to support the use of this code.

6. Documentation requirements

To support a claim for CPT 58540, the provider must document the following information:

• The specific uterine anomaly being repaired (Strassman type)
• The approach used (abdominal)
• The date of the procedure
• A detailed description of the procedure performed
• Any additional findings or procedures performed during the same operative session
• The patient’s response to the procedure
• Any complications or post-operative care provided

7. Billing guidelines

When billing for CPT 58540, ensure that the procedure performed matches the description of the code. It is important to accurately document the specific uterine anomaly being repaired and the approach used. This code should not be reported for the closure of a vesicouterine fistula, which has its own specific code (51920).

8. Historical information

CPT 58540 was added to the Current Procedural Terminology system on January 1, 1990. The code has not undergone any updates since its addition. It is important to use the most current version of the CPT code book when reporting this procedure.

9. Examples

1. A provider performs a Strassman type hysteroplasty to repair a patient’s uterus with two horns, creating a single uterine cavity.
2. During an abdominal procedure, the provider corrects a uterine anomaly of the Strassman type, resulting in a single uterine cavity.
3. A patient undergoes a hysteroplasty to repair a specific uterine anomaly known as the Strassman type, resulting in the creation of a single uterine cavity.
4. The provider performs a surgical procedure to correct a uterine anomaly of the Strassman type, resulting in the repair of the patient’s uterus and the creation of a single uterine cavity.
5. A Strassman type hysteroplasty is performed to repair a patient’s uterus with two horns, creating a single uterine cavity.
6. The provider performs a repair procedure on a patient’s uterus to correct a specific uterine anomaly known as the Strassman type, resulting in the creation of a single uterine cavity.
7. A patient undergoes a surgical procedure to repair a uterine anomaly of the Strassman type, resulting in the correction of the patient’s uterus and the creation of a single uterine cavity.
8. The provider performs a hysteroplasty to repair a specific uterine anomaly known as the Strassman type, resulting in the repair of the patient’s uterus and the creation of a single uterine cavity.
9. A patient undergoes a surgical procedure to correct a uterine anomaly of the Strassman type, resulting in the correction of the patient’s uterus and the creation of a single uterine cavity.
10. The provider performs a repair procedure on a patient’s uterus to correct a specific uterine anomaly known as the Strassman type, resulting in the creation of a single uterine cavity.