How To Use CPT Code 58545

CPT 58545 describes the laparoscopic surgical procedure known as myomectomy. 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 58545?

CPT 58545 is a code used to describe a laparoscopic surgical procedure called myomectomy. This procedure involves the excision of fibroid tumors in the uterus. The provider removes a total of one to four tumors with a total weight of 250 g or less. Additionally, the provider may also remove tumors on the surface of the uterus.

2. Official Description

The official description of CPT code 58545 is: ‘Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 g or less and/or removal of surface myomas.’

3. Procedure

1. The provider begins by placing the patient in the dorsal lithotomy position and administering a general anesthetic.
2. A small incision is made near the belly button, and a laparoscope is inserted to view the abdominal cavity.
3. The abdomen is insufflated with CO2 gas to create a pneumoperitoneum, and small incisions are made to insert trocars for better visualization and access.
4. If performing robotic surgery, the provider docks the robot to the laparoscope.
5. The provider carefully moves the intestines out of the way to access the fibroids.
6. Surface myomas are removed first, followed by intramural myomas.
7. The provider injects a hemostatic drug into the uterine muscle to minimize blood loss.
8. An incision is made over each intramural myoma, and the fibroid is dissected free from the uterine muscle layer.
9. The blood supply to the fibroid is coagulated, and the area is repaired with sutures.
10. This process is repeated for each fibroid.
11. Each fibroid is tagged with a suture for identification.
12. The fibroids are removed from the abdominal cavity, and hemostasis is achieved.
13. The fibroids are morcellated or cut into small strips or pieces using a knife or electrical device.
14. The strips are removed through the trocar sites.
15. The uterine wall incisions are closed, trocars are removed, and the skin incisions are closed.

4. Qualifying circumstances

CPT 58545 is used for patients who require the removal of one to four intramural myomas with a total weight of 250 g or less. The procedure may also involve the removal of surface myomas. It is important to note that the provider must assess the patient’s condition and determine the need for myomectomy.

5. When to use CPT code 58545

CPT code 58545 should be used when a laparoscopic myomectomy is performed to remove one to four intramural myomas with a total weight of 250 g or less. It is important to ensure that the procedure meets the specific criteria outlined in the code description.

6. Documentation requirements

To support a claim for CPT 58545, the provider must document the following information:

• Patient’s diagnosis and the need for myomectomy
• Number and weight of intramural myomas
• Details of any surface myomas removed
• Date of the procedure
• Specific steps taken during the procedure
• Any complications or additional procedures performed
• Signature of the provider

7. Billing guidelines

When billing for CPT 58545, ensure that the procedure meets the specific criteria outlined in the code description. It is important to accurately report the number and weight of the intramural myomas removed. Additionally, consider any additional procedures or complications that may affect the billing. It is also important to follow any specific guidelines provided by the payer or coding guidelines.

8. Historical information

CPT 58545 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 a laparoscopic myomectomy to remove three intramural myomas with a total weight of 200 g.
2. A provider performs a laparoscopic myomectomy to remove two intramural myomas with a total weight of 180 g and also removes two surface myomas.
3. A patient requires a laparoscopic myomectomy to remove four intramural myomas with a total weight of 240 g.
4. A provider performs a laparoscopic myomectomy to remove one intramural myoma with a weight of 100 g and also removes three surface myomas.