How To Use CPT Code 58615

CPT 58615 describes the occlusion of fallopian tube(s) using a device, either through a vaginal or suprapubic approach. 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 58615?

CPT 58615 can be used to describe the procedure in which a healthcare provider uses a device to close off one or both fallopian tubes. This can be done through either a vaginal approach, which involves an incision in the vaginal wall, or a suprapubic approach, which involves an incision just above the pubic bone.

2. Official Description

The official description of CPT code 58615 is: ‘Occlusion of fallopian tube(s) by device (eg, band, clip, Falope ring) vaginal or suprapubic approach.’

3. Procedure

1. The healthcare provider administers a general anesthetic and positions the patient accordingly.
2. For the vaginal approach, the provider exposes the cervix and incises the vaginal wall to access the fallopian tubes. The provider then uses a device, such as a ring or clip, to constrict the narrowest part of the fallopian tube, effectively blocking it.
3. For the suprapubic approach, the provider makes an incision just above the pubic bone to access the fallopian tubes. The same procedure is performed to occlude one or both of the tubes using a device.
4. Finally, the provider closes the incisions with sutures.

4. Qualifying circumstances

CPT 58615 is typically performed on patients who require the occlusion of their fallopian tubes. This procedure may be necessary for various reasons, such as contraception or to treat certain medical conditions. The healthcare provider must use a device, such as a band, clip, or Falope ring, to occlude the tubes. The procedure can be performed through either a vaginal or suprapubic approach.

5. When to use CPT code 58615

CPT code 58615 should be used when a healthcare provider performs the occlusion of fallopian tube(s) using a device. It is important to note that this code should not be reported if the provider only occludes one tube. Modifier 52, which indicates reduced services, should not be added in this case.

6. Documentation requirements

To support a claim for CPT 58615, the healthcare provider must document the following information:

• Patient’s diagnosis or reason for the procedure
• Approach used (vaginal or suprapubic)
• Details of the procedure, including the device used
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the healthcare provider

7. Billing guidelines

When billing for CPT 58615, ensure that the procedure is performed using a device to occlude the fallopian tube(s) through either a vaginal or suprapubic approach. It is important to note that this code should not be reported with modifier 52 if only one tube is occluded. Review the specific guidelines provided by the payer to ensure accurate billing.

8. Historical information

CPT 58615 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A healthcare provider performs the occlusion of both fallopian tubes using a clip through a vaginal approach for a patient seeking permanent contraception.
2. Using a suprapubic approach, a healthcare provider occludes one fallopian tube using a band for a patient with a history of ectopic pregnancies.
3. A patient with a genetic disorder undergoes the occlusion of both fallopian tubes using a Falope ring through a vaginal approach to prevent the transmission of the condition.
4. A healthcare provider performs the occlusion of one fallopian tube using a clip through a suprapubic approach for a patient with a history of pelvic inflammatory disease.
5. Using a vaginal approach, a healthcare provider occludes both fallopian tubes using a band for a patient who has completed her desired family size.
6. A patient with a high risk of ovarian cancer undergoes the occlusion of both fallopian tubes using a Falope ring through a suprapubic approach.
7. A healthcare provider performs the occlusion of one fallopian tube using a clip through a vaginal approach for a patient with a history of recurrent miscarriages.
8. Using a suprapubic approach, a healthcare provider occludes both fallopian tubes using a band for a patient with a genetic predisposition to breast cancer.
9. A patient with a history of failed contraception methods undergoes the occlusion of both fallopian tubes using a Falope ring through a vaginal approach.
10. A healthcare provider performs the occlusion of one fallopian tube using a clip through a suprapubic approach for a patient with a history of tubal pregnancies.