How To Use CPT Code 58554

CPT 58554 describes the laparoscopic surgical procedure with vaginal hysterectomy for a uterus weighing more than 250 grams, including the removal of the fallopian tubes and/or ovaries. 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 58554?

CPT 58554 is used to describe a laparoscopic surgical procedure with vaginal hysterectomy for a uterus weighing more than 250 grams. This procedure involves the removal of the uterus, cervix, and fallopian tubes, with or without the ovaries, through the vagina. The upper uterine and ovarian attachments are cut using a laparoscope. This procedure is typically performed to treat fibroids in a larger than normal uterus.

2. Official Description

The official description of CPT code 58554 is: ‘Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s).’ It is important to note that this code should not be reported in conjunction with certain other codes, as specified in the notes.

3. Procedure

1. The patient is placed in the dorsal lithotomy position, and the abdomen is prepped and draped.
2. A general anesthetic is administered, and the provider enters the abdominal cavity near the belly button using a Veress needle or an open incision.
3. A laparoscope is inserted to view the abdominal and pelvic contents, and the abdomen is insufflated with CO2 gas to create a pneumoperitoneum.
4. Small incisions are made around the abdominal area to insert trocars, which allow for better visualization and the insertion of surgical tools.
5. If robotic surgery is being performed, the robot is docked to the laparoscope.
6. The provider removes any fibroids present in the uterus before proceeding with the removal of the uterus.
7. The provider cuts and cauterizes the infundibulopelvic ligaments, round ligaments, fallopian tubes, and ovarian ligaments.
8. The uterus is moved to one side using a uterine manipulator, and the provider incises the broad ligament and extends it downward toward the cervix.
9. The provider identifies the ureters and the uterine artery and vein, and incises the vessels close to the ureters.
10. The bladder is freed up, and the gas is released from the abdomen.
11. The provider makes a circular incision in the vaginal wall around the cervix and enters the anterior and posterior cul-de-sac.
12. The uterosacral and cardinal ligaments are clamped and incised, and the uterus is freed from the broad ligament.
13. The uterus, along with the fallopian tubes and/or ovaries, is brought out of the body through the vagina.
14. Bleeding is controlled with cautery and sutures, and the vaginal cuff is closed from below.
15. The trocars are removed, and the abdominal incisions are closed with sutures.

4. Qualifying circumstances

CPT 58554 is typically performed for patients with fibroids in a uterus weighing more than 250 grams. The procedure is done by a provider who is experienced in laparoscopic surgical techniques. It is important to note that certain other procedures should not be reported in conjunction with CPT 58554, as specified in the notes.

5. When to use CPT code 58554

CPT code 58554 should be used when performing a laparoscopic surgical procedure with vaginal hysterectomy for a uterus weighing more than 250 grams. It is important to ensure that the procedure meets the specific criteria outlined in the code description. This code should not be used in conjunction with certain other codes, as specified in the notes.

6. Documentation requirements

To support a claim for CPT 58554, the following documentation is typically required:

• Documentation of the patient’s diagnosis and the need for the procedure
• Details of the laparoscopic surgical procedure performed, including the removal of the uterus, cervix, and fallopian tubes
• Date of the procedure
• Start and end time of the procedure
• Specific details of the steps taken during the procedure, including the use of laparoscopic tools and techniques
• Documentation of any complications or unexpected findings during the procedure
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 58554, it is important to ensure that the procedure meets the specific criteria outlined in the code description. The procedure should be performed by a provider experienced in laparoscopic surgical techniques. It is also important to note that certain other procedures should not be reported in conjunction with CPT 58554, as specified in the notes. Additional billing guidelines may vary depending on the specific payer and coding guidelines.

8. Historical information

CPT 58554 was added to the Current Procedural Terminology system on January 1, 2003. There have been historical changes to the code, including a code change on January 1, 2007, which updated the description of the procedure.

9. Examples

1. A patient with multiple fibroids in a uterus weighing more than 250 grams undergoes a laparoscopic surgical procedure with vaginal hysterectomy, including the removal of the fallopian tubes and ovaries.