How To Use CPT Code 58575

CPT 58575 describes the laparoscopic surgical procedure for total hysterectomy with omentectomy, including salpingo-oophorectomy, when performed for the resection of malignancy. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 58575?

CPT 58575 is used to describe a laparoscopic surgical procedure that involves the removal of the uterus, cervix, ovaries, fallopian tubes, and the entire omentum. This procedure is performed when there is a malignancy that requires resection. It is important to note that CPT 58575 should not be reported in conjunction with certain other codes, such as 49255, 49320, 49321, 58570, 58571, 58572, 58573, and 58661.

2. Official Description

The official description of CPT code 58575 is: ‘Laparoscopy, surgical, total hysterectomy for resection of malignancy (tumor debulking), with omentectomy including salpingo-oophorectomy, unilateral or bilateral, when performed.’

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, and the provider enters the abdominal cavity using a Veress needle or an open incision near the belly button.
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 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. A combination manipulator-colpotomizer device is placed into the uterus through the cervix to facilitate movement and guide incisions.
7. The provider identifies and dissects the ureters to ensure they are not injured during the surgery.
8. The infundibulopelvic ligaments and veins are desiccated, and the round ligaments are incised to free the uterus from the broad ligament.
9. The provider incises the infundibulopelvic ligaments and mobilizes the bladder off the lower uterine segment.
10. The uterine arteries are stripped and ligated, and the cardinal and uterosacral ligaments are clamped and incised.
11. A circular incision is made around the anterior and posterior vagina using the colpotomizer-uterine manipulator as a guide.
12. The uterus, cervix, fallopian tubes, and ovaries are removed through the vagina or trocar ports.
13. The omentum is excised, taking care to remove all tumors.
14. The vaginal cuff is sutured, and the abdominal cavity is deflated and closed.

4. Qualifying circumstances

CPT 58575 is performed when there is a malignancy that requires the removal of the uterus, cervix, ovaries, fallopian tubes, and omentum. It is important to note that CPT 58575 should not be reported in conjunction with certain other codes, such as 49255, 49320, 49321, 58570, 58571, 58572, 58573, and 58661.

5. When to use CPT code 58575

CPT code 58575 should be used when performing a laparoscopic surgical procedure for the total hysterectomy with omentectomy, including salpingo-oophorectomy, for the resection of malignancy. 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 58575, the following documentation is required:

• Documentation of the malignancy requiring resection
• Details of the laparoscopic surgical procedure performed
• Date of the procedure
• Start and end time of the procedure
• Specific organs and tissues removed
• Confirmation of no bleeding or complications
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 58575, it is important to ensure that the procedure meets the specific criteria outlined in the code description. CPT 58575 should not be reported in conjunction with certain other codes, such as 49255, 49320, 49321, 58570, 58571, 58572, 58573, and 58661. It is important to review the billing guidelines and any additional requirements from the payer to ensure accurate and appropriate billing.

8. Historical information

CPT 58575 was added to the Current Procedural Terminology system on January 1, 2018. It was also added to the Inpatient Only (IPO) list for Medicare in 2018.

9. Examples

1. A patient undergoes a laparoscopic total hysterectomy with omentectomy, including salpingo-oophorectomy, for the resection of ovarian cancer.
2. A provider performs a laparoscopic total hysterectomy with omentectomy, including salpingo-oophorectomy, for the resection of endometrial cancer.