How To Use CPT Code 58548

CPT 58548 describes the laparoscopic surgical procedure that involves a radical hysterectomy, bilateral total pelvic lymphadenectomy, para-aortic lymph node sampling, and the removal of the fallopian tubes and ovaries if necessary. 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 58548?

CPT 58548 is a code used to describe a laparoscopic surgical procedure that involves the removal of the uterus, fallopian tubes, ovaries, parametrium, cardinal and uterosacral ligaments, as well as the excision of pelvic lymph nodes on both sides of the body and sampling of para-aortic lymph nodes. This procedure is performed using small incisions and a laparoscope, a fiberoptic instrument that allows the provider to visualize and operate on the abdominal and pelvic contents.

2. Official Description

The official description of CPT code 58548 is: ‘Laparoscopy, surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with removal of tube(s) and ovary(s), if performed.’

3. Procedure

1. The patient is positioned in the dorsal lithotomy position and administered a general anesthetic.
2. The provider makes small incisions in the abdominal area and inserts trocars to create portals for the laparoscope and surgical tools.
3. The provider insufflates the abdomen with CO2 gas to create a pneumoperitoneum, allowing for better visualization of the surgical site.
4. The provider removes the uterus, fallopian tubes, ovaries, parametrium, cardinal and uterosacral ligaments, and excises the pelvic lymph nodes on both sides of the body.
5. The provider also takes samples of the para-aortic lymph nodes.
6. The provider closes the incisions and releases the CO2 gas from the abdomen.

4. Qualifying circumstances

CPT 58548 is typically performed on patients who require a radical hysterectomy, bilateral total pelvic lymphadenectomy, and para-aortic lymph node sampling. This procedure is indicated for conditions such as gynecologic cancers, endometriosis, and certain benign conditions that cannot be treated with less invasive methods. The patient must meet specific criteria for the procedure, which is determined by the provider based on the patient’s medical history and condition.

5. When to use CPT code 58548

CPT code 58548 should be used when a laparoscopic surgical procedure involving a radical hysterectomy, bilateral total pelvic lymphadenectomy, and para-aortic lymph node sampling is performed. It is important to ensure that the procedure meets the specific criteria outlined in the official description of the code. This code should not be reported in conjunction with certain other codes, as indicated in the notes provided.

6. Documentation requirements

To support a claim for CPT code 58548, the provider must document the following information:

• Patient’s diagnosis and the medical necessity for the procedure
• Details of the laparoscopic surgical procedure performed, including the specific structures removed and lymph nodes sampled
• Date of the procedure
• Start and end time of the procedure
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 58548, it is important to ensure that the procedure meets the specific criteria outlined in the official description. The provider should also be aware of any additional guidelines or restrictions provided in the notes. It is important to accurately report the procedure and any associated services or supplies provided during the surgery.

8. Historical information

CPT code 58548 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. However, it is important to stay updated with any changes or revisions to the code in order to accurately report and bill for the procedure.

9. Examples

1. A patient with endometrial cancer undergoes a laparoscopic procedure involving a radical hysterectomy, bilateral total pelvic lymphadenectomy, and para-aortic lymph node sampling.
2. A patient with ovarian cancer undergoes a laparoscopic procedure involving a radical hysterectomy, bilateral total pelvic lymphadenectomy, and para-aortic lymph node sampling.
3. A patient with cervical cancer undergoes a laparoscopic procedure involving a radical hysterectomy, bilateral total pelvic lymphadenectomy, and para-aortic lymph node sampling.
4. A patient with uterine fibroids undergoes a laparoscopic procedure involving a radical hysterectomy, bilateral total pelvic lymphadenectomy, and para-aortic lymph node sampling.
5. A patient with endometriosis undergoes a laparoscopic procedure involving a radical hysterectomy, bilateral total pelvic lymphadenectomy, and para-aortic lymph node sampling.
6. A patient with pelvic inflammatory disease undergoes a laparoscopic procedure involving a radical hysterectomy, bilateral total pelvic lymphadenectomy, and para-aortic lymph node sampling.