How To Use CPT Code 58550

CPT 58550 describes the laparoscopic surgical procedure of removing the uterus and cervix through the vagina for a uterus weighing 250 grams or less. 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 58550?

CPT 58550 can be used to describe the laparoscopic surgical procedure in which the provider removes the uterus and cervix through the vagina. This procedure is specifically performed for uteruses weighing 250 grams or less.

2. Official Description

The official description of CPT code 58550 is: ‘Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less.’

3. Procedure

1. The provider places 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.
4. Additional small incisions are made to insert trocars, which allow for better visualization and the use of surgical tools.
5. If performing robotic surgery, the robot is docked to the laparoscope.
6. A uterine manipulator is inserted into the uterus to facilitate movement during the procedure.
7. The provider identifies and incises the round ligaments, fallopian tubes, and ovarian ligaments.
8. The broad ligament is incised, and the incision is extended downward toward the cervix.
9. The provider identifies and incises the uterine artery and vein, as well as the ureters.
10. The bladder is freed up.
11. The gas is released from the abdomen, and the vaginal part of the procedure begins.
12. A circular incision is made in the vaginal wall around the cervix.
13. The provider enters the anterior and posterior cul-de-sac.
14. The uterosacral and cardinal ligaments are clamped and incised.
15. The uterus is freed from the broad ligament and removed through the vagina.
16. Any remaining ovaries are identified and controlled for bleeding.
17. The peritoneum and vaginal cuff are closed.
18. The trocars are removed, and the abdominal incisions are closed with sutures.

4. Qualifying circumstances

CPT 58550 is performed on patients with a uterus weighing 250 grams or less. It is important to note that this procedure is specifically for the removal of the uterus and cervix through the vagina using a laparoscopic approach.

5. When to use CPT code 58550

CPT code 58550 should be used when the provider performs a laparoscopic surgical procedure to remove the uterus and cervix through the vagina for a uterus weighing 250 grams 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 58550, the provider must document the following information:

• Patient’s diagnosis and the need for the procedure
• Details of the laparoscopic approach, including the use of a laparoscope and trocars
• Specific steps performed during the procedure, such as incisions, ligament incisions, and vessel control
• Confirmation of the uterus weighing 250 grams or less
• Details of the vaginal part of the procedure, including incisions and closure
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 58550, ensure that the procedure meets the specific criteria outlined in the code description. It is important to accurately document the details of the procedure and any additional services provided. CPT code 58550 should not be reported with other codes unless additional procedures were performed. It is important to follow the specific guidelines and rules set forth by the payer when submitting claims for reimbursement.

8. Historical information

CPT 58550 was added to the Current Procedural Terminology system on January 1, 2000. There have been several changes to the code description since its addition, including updates to the wording and inclusion of specific weight criteria for the uterus.

9. Examples

1. A provider performs a laparoscopic surgical procedure to remove the uterus and cervix through the vagina for a patient with a uterus weighing 200 grams.
2. Using a laparoscopic approach, the provider removes the uterus and cervix through the vagina for a patient with a uterus weighing 180 grams.
3. For a patient with a uterus weighing 240 grams, the provider performs a laparoscopic surgical procedure to remove the uterus and cervix through the vagina.
4. A laparoscopic surgical procedure is performed to remove the uterus and cervix through the vagina for a patient with a uterus weighing 220 grams.
5. The provider removes the uterus and cervix through the vagina using a laparoscopic approach for a patient with a uterus weighing 250 grams.
6. Using a laparoscopic approach, the provider performs a surgical procedure to remove the uterus and cervix through the vagina for a patient with a uterus weighing 210 grams.
7. A patient with a uterus weighing 230 grams undergoes a laparoscopic surgical procedure to remove the uterus and cervix through the vagina.