How To Use CPT Code 58546

CPT 58546 describes the laparoscopic surgical procedure known as myomectomy. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 58546?

CPT 58546 can be used to describe a laparoscopic surgical procedure called myomectomy. This code is used when the provider removes five or more intramural fibroid tumors from the uterus, or any number of fibroid tumors that have a total weight greater than 250 grams.

2. Official Description

The official description of CPT code 58546 is: ‘Laparoscopy, surgical, myomectomy, excision; 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 g.’

3. Procedure

1. The provider positions the patient in the dorsal lithotomy position and administers 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 additional small incisions are made to insert trocars for surgical tools.
4. If performing robotic surgery, the provider docks the robot to the laparoscope.
5. The provider carefully moves the intestines to better access the fibroids and injects a hemostatic drug into the uterine muscle to minimize blood loss.
6. The provider uses a scalpel to incise the area over each fibroid and dissects it free from the uterine muscle using sharp and blunt dissection techniques.
7. The blood supply to each fibroid is coagulated, and the area is repaired with sutures.
8. The provider repeats this procedure for each fibroid, tagging them with sutures for identification.
9. After all the fibroids are removed, the provider retrieves each tagged fibroid, morcellates them into small strips or pieces, and removes them from the abdomen through the trocar sites.
10. The trocar sites and skin incisions are closed to complete the procedure.

4. Qualifying circumstances

CPT 58546 is used for patients who require the removal of five or more intramural fibroid tumors from the uterus, or any number of fibroid tumors that have a total weight greater than 250 grams. The procedure is performed using a laparoscope by a qualified provider.

5. When to use CPT code 58546

CPT code 58546 should be used when the provider performs a laparoscopic myomectomy and removes five or more intramural fibroid tumors, or any number of fibroid tumors with a total weight greater than 250 grams. This code should not be used for the removal of surface fibroids or when the total weight of the fibroids is less than 250 grams.

6. Documentation requirements

To support a claim for CPT 58546, the provider must document the following information:

• Patient’s diagnosis and the need for myomectomy
• Number of fibroid tumors removed or total weight of the fibroids
• Date of the procedure
• Specific details of the procedure, including the use of laparoscopy and any additional techniques or tools used
• Any complications or unexpected findings during the procedure
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 58546, ensure that the procedure meets the criteria of removing five or more intramural fibroid tumors, or any number of fibroid tumors with a total weight greater than 250 grams. It is important to accurately document the details of the procedure and any additional techniques or tools used. CPT code 58546 should not be reported for the removal of surface fibroids or when the total weight of the fibroids is less than 250 grams. It is also important to follow any specific guidelines or requirements from the payer when submitting the claim.

8. Historical information

CPT 58546 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 provider performs a laparoscopic myomectomy and removes six intramural fibroid tumors from the uterus, each weighing between 50 and 100 grams.
2. A patient undergoes a laparoscopic myomectomy, and the provider removes seven intramural fibroid tumors with a total weight of 300 grams.
3. A provider performs a laparoscopic myomectomy and removes five intramural fibroid tumors, each weighing between 30 and 60 grams.
4. A patient requires a laparoscopic myomectomy, and the provider removes eight intramural fibroid tumors with a total weight of 280 grams.
5. A provider performs a laparoscopic myomectomy and removes six intramural fibroid tumors, each weighing between 40 and 80 grams.
6. A patient undergoes a laparoscopic myomectomy, and the provider removes five intramural fibroid tumors with a total weight of 200 grams.
7. A provider performs a laparoscopic myomectomy and removes seven intramural fibroid tumors, each weighing between 60 and 120 grams.
8. A patient requires a laparoscopic myomectomy, and the provider removes six intramural fibroid tumors with a total weight of 270 grams.