How To Use CPT Code 58571

CPT 58571 describes the laparoscopic surgical procedure for a total hysterectomy, specifically for a uterus weighing 250 g or less, with 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 58571?

CPT 58571 is a code used to describe a laparoscopic surgical procedure known as a total hysterectomy. This procedure involves the removal of the uterus, cervix, and fallopian tubes, with or without the ovaries, for patients whose uterus weighs 250 g or less. It is important to note that this code specifically applies to laparoscopic procedures.

2. Official Description

The official description of CPT code 58571 is: ‘Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s).’ This code is used when the provider performs a laparoscopic total hysterectomy on a patient with a uterus weighing 250 g or less, and may involve the removal of the fallopian tubes and/or ovaries.

3. Procedure

1. The patient is positioned in the dorsal lithotomy position, and the abdomen is prepped and draped.
2. A general anesthetic is administered to the patient.
3. The provider enters the abdominal cavity near the belly button using a Veress needle or an open incision.
4. A laparoscope is inserted to view the abdominal and pelvic contents.
5. The abdomen is insufflated with CO2 gas to create a pneumoperitoneum.
6. Small incisions are made around the abdominal area to insert trocars, which allow for the insertion of surgical tools.
7. If performing robotic surgery, the robot is docked to the laparoscope.
8. A combination uterine manipulator-colpotomizer device is inserted into the uterus through the cervix to facilitate movement and guide incisions.
9. The provider identifies and dissects the ureters to ensure they are not cut during the surgery.
10. The infundibulopelvic ligaments and veins are desiccated using a heated instrument.
11. The round ligaments are incised, and the uterus is dissected from the broad ligament.
12. The infundibulopelvic ligaments are incised, and the bladder is mobilized off the lower uterine segment.
13. The uterine arteries are stripped and ligated.
14. The cardinal and uterosacral ligaments are incised and clamped.
15. A circular incision is made around the anterior and posterior vagina using the colpotomizer.
16. The uterus, cervix, and fallopian tubes are removed through the vagina.
17. If necessary, a morcellator may be used to reduce the size of the uterus for removal through one of the trocar ports.
18. A sponge or device is placed in the vaginal cuff area, and the abdominal cavity is reinflated.
19. The vaginal cuff is sutured through the laparoscope, and the uterosacral tissues are folded and shortened to prevent the formation of an enterocele.
20. The abdomen is checked for bleeding, and the gas is deflated.
21. All instruments and trocars are removed, and the trocar sites are closed with sutures.

4. Qualifying circumstances

CPT 58571 is used for patients who require a laparoscopic total hysterectomy and meet the following criteria:

• The patient has a uterus weighing 250 g or less.
• The procedure involves the removal of the fallopian tubes and/or ovaries.
• The surgery is performed using a laparoscopic approach.

5. When to use CPT code 58571

CPT code 58571 should be used when a laparoscopic total hysterectomy is performed on a patient with a uterus weighing 250 g or less, and when the procedure includes the removal of the fallopian tubes and/or ovaries. It is important to note that this code is specific to laparoscopic procedures and should not be used for other types of hysterectomies.

6. Documentation requirements

To support a claim for CPT code 58571, the following documentation is required:

• Confirmation of the patient’s diagnosis and the need for a laparoscopic total hysterectomy.
• Documentation of the patient’s uterus weighing 250 g or less.
• Details of the procedure, including the use of a laparoscopic approach and the removal of the fallopian tubes and/or ovaries.
• Date of the procedure and the start and end times.
• Any additional relevant information, such as complications or additional procedures performed.
• Signature of the provider performing the procedure.

7. Billing guidelines

When billing for CPT code 58571, ensure that the procedure meets the criteria for a laparoscopic total hysterectomy with the removal of the fallopian tubes and/or ovaries for a uterus weighing 250 g or less. It is important to follow the specific guidelines for reporting this code and to ensure accurate documentation to support the claim. Additionally, be aware of any specific billing requirements or modifiers that may be necessary for proper reimbursement.

8. Historical information

CPT code 58571 was added to the Current Procedural Terminology system on January 1, 2008. There have been no updates or changes to the code since its addition.

9. Similar codes to CPT 58571

Five similar codes to CPT 58571 include:

• CPT 58540: Hysteroscopy, surgical; with total hysterectomy.
• CPT 58542: Laparoscopy, surgical, with total hysterectomy; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy).
• CPT 58543: Laparoscopy, surgical, with total hysterectomy; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy), with removal of tube(s) and/or ovary(s).