How To Use CPT Code 58541

CPT 58541 describes the laparoscopic surgical procedure known as supracervical hysterectomy. 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 58541?

CPT 58541 is a code used to describe a laparoscopic surgical procedure called supracervical hysterectomy. This procedure involves the removal of the uterus using a laparoscope, while leaving the cervix and the fallopian tubes and ovaries intact. The uterus being removed should weigh 250 grams or less.

2. Official Description

The official description of CPT code 58541 is: ‘Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less.’

3. Procedure

1. The patient is positioned in the dorsal lithotomy position.
2. The provider preps and drapes the abdomen and administers a general anesthetic.
3. A Veress needle or an open incision is used to enter the abdominal cavity near the belly button.
4. A laparoscope is placed to visualize the abdominal cavity.
5. The abdomen is insufflated with CO2 gas to create a pneumoperitoneum.
6. Small incisions are made around the abdominal area to insert trocars for better visualization and to insert surgical tools.
7. If performing robotic surgery, the robot is docked to the laparoscope.
8. The provider opens the peritoneum over the bladder and dissects the bladder off the lower uterine segment.
9. The provider incises the attachments of the uterus, including the round ligaments, and removes any fibroids if present.
10. The uterine artery is identified, clamped, and incised.
11. The provider separates the fundus of the uterus from the cervix using a scalpel and treats any bleeding from the cervical stump.
12. A morcellator is used to cut the uterus into small pieces, which are then removed from the abdominal cavity through one or more of the trocar sites.
13. The provider deflates the abdominal cavity, removes all instruments and trocars, and closes the trocar site fascia and skin.

4. Qualifying circumstances

CPT 58541 is performed on patients with a uterus weighing 250 grams or less who require a supracervical hysterectomy. The procedure is typically performed by a provider using a laparoscope and is suitable for patients who do not require the removal of the cervix or the fallopian tubes and ovaries.

5. When to use CPT code 58541

CPT code 58541 should be used when a laparoscopic supracervical hysterectomy is performed on a patient with a uterus weighing 250 grams or less. It should not be used when the uterus weighs more than 250 grams or when additional procedures, such as the removal of fibroids, are performed.

6. Documentation requirements

To support a claim for CPT 58541, the provider must document the following information:

• Patient’s diagnosis and the need for a supracervical hysterectomy
• Confirmation that the uterus weighs 250 grams or less
• Date of the procedure
• Details of the procedure, including the use of laparoscopy and any additional techniques or instruments used
• Any complications or unexpected findings during the procedure
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 58541, ensure that the procedure meets the criteria for a laparoscopic supracervical hysterectomy for a uterus weighing 250 grams or less. It should not be reported if the uterus weighs more than 250 grams or if additional procedures are performed. It is important to follow any specific guidelines provided by the payer regarding documentation and coding for this procedure.

8. Historical information

CPT 58541 was added to the Current Procedural Terminology system on January 1, 2007. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient with a uterus weighing 200 grams undergoes a laparoscopic supracervical hysterectomy.
2. A provider performs a laparoscopic supracervical hysterectomy on a patient with a uterus weighing 240 grams.
3. A laparoscopic supracervical hysterectomy is performed on a patient with a uterus weighing 220 grams.
4. A provider uses laparoscopy to perform a supracervical hysterectomy on a patient with a uterus weighing 230 grams.
5. A laparoscopic supracervical hysterectomy is performed on a patient with a uterus weighing 250 grams.
6. A provider performs a laparoscopic supracervical hysterectomy on a patient with a uterus weighing 210 grams.
7. A patient with a uterus weighing 190 grams undergoes a laparoscopic supracervical hysterectomy.
8. A provider performs a laparoscopic supracervical hysterectomy on a patient with a uterus weighing 225 grams.
9. A laparoscopic supracervical hysterectomy is performed on a patient with a uterus weighing 235 grams.
10. A provider uses laparoscopy to perform a supracervical hysterectomy on a patient with a uterus weighing 215 grams.