How To Use CPT Code 58572

CPT 58572 describes the laparoscopic surgical procedure for a total hysterectomy when the uterus weighs more than 250 g. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 58572?

CPT 58572 is used to describe a laparoscopic surgical procedure for a total hysterectomy when the uterus weighs more than 250 g. This code is specifically used when the provider makes incisions through the laparoscope to remove the uterus and cervix either through the trocar ports or through the vaginal canal. The procedure is typically performed to address conditions such as fibroids that cause the uterus to be larger than normal.

2. Official Description

The official description of CPT code 58572 is: ‘Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g.’

3. Procedure

1. The patient is positioned in the dorsal lithotomy position and prepared for surgery.
2. The provider administers a general anesthetic to the patient.
3. The provider enters the abdominal cavity using a Veress needle or an open incision near the belly button.
4. A laparoscope is inserted to visualize the abdominal and pelvic contents.
5. The provider insufflates the abdomen with CO2 gas to create a pneumoperitoneum.
6. Small incisions are made around the abdominal area to insert trocars, which allow for better visualization and the insertion of surgical tools.
7. If performing robotic surgery, the provider docks the robot to the laparoscope.
8. A combination uterine manipulator-colpotomizer device is inserted into the uterus through the cervix to facilitate manipulation and guide incisions.
9. The provider identifies and dissects the ureters to ensure their safety during the procedure.
10. The infundibulopelvic ligaments and veins between the ovary and round ligaments are desiccated using a heated instrument.
11. The round ligaments are incised, and the uterus is dissected from the anterior and posterior broad ligament.
12. The ovarian ligaments are incised, and the bladder is mobilized off the lower uterine segment.
13. The uterine arteries are stripped from the surrounding tissue 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. If the uterus is larger than normal, a morcellator may be used to reduce its size.
17. The uterus and cervix are removed either through the vaginal canal or in pieces 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 these sutures are used to fold and shorten the uterosacral tissues.
20. The provider ensures there is no bleeding, deflates the abdomen, and removes all instruments and trocars.
21. All trocar sites are closed with sutures at the level of both the fascia and the skin.

4. Qualifying circumstances

CPT 58572 is performed when the patient’s uterus weighs more than 250 g, typically due to the presence of fibroids or other conditions. The procedure is indicated for patients who require a total hysterectomy and are suitable candidates for laparoscopic surgery. The provider must assess the patient’s condition and determine the appropriateness of using CPT 58572 based on the weight of the uterus and the patient’s overall health.

5. When to use CPT code 58572

CPT code 58572 should be used when performing a laparoscopic surgical procedure for a total hysterectomy on a patient with a uterus weighing more than 250 g. It is important to accurately document the weight of the uterus and ensure that the procedure meets the criteria outlined in the code description. If the uterus weighs 250 g or less, a different CPT code should be used to report the procedure.

6. Documentation requirements

To support a claim for CPT 58572, the provider must document the following information:

• Weight of the uterus
• Details of the laparoscopic surgical procedure performed
• Specific incisions made and instruments used
• Any complications or additional procedures performed
• Start and end time of the procedure
• Any additional relevant information or findings
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 58572, ensure that the procedure meets the criteria outlined in the code description, including the weight of the uterus. It is important to accurately document the details of the procedure and any additional services provided. CPT 58572 should not be reported with other codes that describe different procedures or services. It is essential to follow the specific guidelines provided by the payer and use appropriate modifiers if necessary.

8. Historical information

CPT 58572 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. Examples

1. A patient with multiple fibroids undergoes a laparoscopic total hysterectomy with CPT code 58572.