How To Use CPT Code 58553

CPT 58553 describes the laparoscopic surgical procedure of removing the uterus and cervix through the vagina, known as a vaginal hysterectomy, for a uterus that weighs more than 250 grams. 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 58553?

CPT 58553 is a code used to describe a laparoscopic surgical procedure called a vaginal hysterectomy. This procedure involves the removal of the uterus and cervix through the vagina. It is performed when the uterus weighs more than 250 grams, indicating that it is larger than normal. The procedure is typically done to treat conditions such as fibroids.

2. Official Description

The official description of CPT code 58553 is: ‘Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g.’

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 open incision is used to enter the abdominal cavity near the belly button.
4. A laparoscope is inserted to view the abdominal cavity, and CO2 gas is used to create a pneumoperitoneum.
5. Small incisions are made in the abdominal area to insert trocars for better visualization and to introduce surgical tools.
6. If performing robotic surgery, the robot is docked to the laparoscope.
7. A uterine manipulator is inserted into the uterus to facilitate the cutting of upper uterine attachments.
8. The provider removes fibroids from the uterus, either by incising them from the surface or excising them from the muscular layer.
9. The round ligaments, fallopian tubes, ovarian ligaments, and broad ligament are incised and cauterized.
10. The provider moves the uterus to one side using the uterine manipulator and incises the broad ligament downward toward the cervix.
11. The uterine artery and vein are incised close to the ureters, and the bladder is freed up.
12. The gas is released from the abdomen, and the provider proceeds to the vaginal part of the procedure.
13. A circular incision is made in the vaginal wall around the cervix, and the anterior and posterior cul-de-sac are entered.
14. The uterosacral and cardinal ligaments are clamped and incised, and the uterus is freed from the broad ligament.
15. The uterus and tagged fibroids are removed through the vagina.
16. The remaining ovaries are identified and any bleeding is controlled with cautery and sutures.
17. The peritoneum and vaginal cuff are closed, and the trocars are removed.
18. The abdominal incisions are closed with sutures.

4. Qualifying circumstances

CPT 58553 is performed on patients with a uterus that weighs more than 250 grams, indicating a larger than normal uterus. This procedure is typically done to treat conditions such as fibroids. It is important to note that the procedure involves both laparoscopic and vaginal components.

5. When to use CPT code 58553

CPT code 58553 should be used when performing a laparoscopic surgical procedure with a vaginal hysterectomy for a uterus that weighs more than 250 grams. It is important to ensure that the uterus meets the weight requirement and that both the laparoscopic and vaginal components are performed.

6. Documentation requirements

To support a claim for CPT 58553, the following documentation is required:

• Confirmation of the uterus weighing more than 250 grams
• Details of the laparoscopic and vaginal components of the procedure
• Date and duration of the procedure
• Specific steps taken during the procedure, including the removal of fibroids
• Identification and control of any bleeding
• Closure of the peritoneum, vaginal cuff, and abdominal incisions

7. Billing guidelines

When billing for CPT 58553, ensure that the procedure meets the criteria of a laparoscopic surgical procedure with a vaginal hysterectomy for a uterus weighing more than 250 grams. It is important to follow the specific documentation requirements and guidelines for reporting this code accurately. Additionally, be aware of any other codes that may need to be reported in conjunction with CPT 58553 and follow any specific billing guidelines provided by payers.

8. Historical information

CPT 58553 was added to the Current Procedural Terminology system on January 1, 2003. Since then, there have been changes to the code description, including updates to the weight requirement for the uterus.

9. Examples

1. A patient undergoes a laparoscopic surgical procedure with a vaginal hysterectomy for a uterus weighing 300 grams due to the presence of fibroids.
2. A provider performs a laparoscopic surgical procedure with a vaginal hysterectomy for a uterus weighing 280 grams to treat a patient’s abnormal uterine bleeding.
3. A laparoscopic surgical procedure with a vaginal hysterectomy is performed on a patient with a uterus weighing 270 grams to address symptoms caused by adenomyosis.
4. A provider removes a uterus weighing 260 grams through a laparoscopic surgical procedure with a vaginal hysterectomy to treat a patient’s pelvic pain.