How To Use CPT Code 58671

CPT 58671 describes the laparoscopic procedure of occluding the oviducts using a device, such as a band, clip, or Falope ring. This article will provide an overview of CPT code 58671, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 58671?

CPT 58671 is a code used to describe a laparoscopic procedure in which the provider uses a device to close off the fallopian tubes. This procedure is performed using a laparoscope, a fiberoptic instrument inserted through small incisions in the abdominal wall. The provider identifies each fallopian tube and constricts the narrowest part using a ring or clip. This occlusion of the oviducts prevents the passage of eggs from the ovaries to the uterus, effectively sterilizing the patient.

2. Official Description

The official description of CPT code 58671 is: ‘Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring).’ This code specifically refers to the laparoscopic procedure of closing off the fallopian tubes using a device.

3. Procedure

1. The patient is positioned in the dorsal lithotomy position, with knees bent and spread apart using stirrups.
2. The provider preps and drapes the abdomen and administers a general anesthetic.
3. A uterine manipulator is inserted through the cervix to facilitate movement of the uterus during the procedure.
4. The provider enters the abdominal cavity near the belly button using a Veress needle or an open incision and inserts a laparoscope.
5. The abdomen is insufflated with CO2 gas to create a pneumoperitoneum, and the patient is placed in the Trendelenburg position.
6. Small incisions are made around the abdominal area to insert trocars, which allow for better visualization and the insertion of surgical tools.
7. The provider identifies each fallopian tube and traces it to its fimbriated end.
8. A device, such as a band, clip, or Falope ring, is used to constrict the narrowest part of each fallopian tube.
9. The provider ensures that the constriction of the device is sufficient to block the fallopian tube.
10. If necessary, a portion of the fallopian tube may be removed for further examination.
11. The abdominal cavity is irrigated and deflated, and all instruments and trocars are removed.
12. The trocar site fascia and skin are closed, and all instruments are removed from the vagina.

4. Qualifying circumstances

CPT 58671 is typically performed on patients who desire permanent sterilization. It is important to note that this procedure is intended for occluding both fallopian tubes. If only one tube is occluded, modifier 52, Reduced services, should be appended to the code. The procedure is performed by a provider using a laparoscope and a device, such as a band, clip, or Falope ring, to block the fallopian tubes.

5. When to use CPT code 58671

CPT code 58671 should be used when a laparoscopic procedure is performed to occlude the oviducts using a device. This code is appropriate for cases where both fallopian tubes are occluded. If only one tube is occluded, modifier 52 should be appended to indicate reduced services. It is important to review the documentation and ensure that the procedure performed aligns with the description provided by CPT code 58671.

6. Documentation requirements

To support a claim for CPT code 58671, the following documentation is required:

• Patient’s medical record, including the reason for the procedure
• Description of the laparoscopic procedure performed
• Details of the device used for occlusion
• Date of the procedure
• Start and end time of the procedure
• Any additional procedures or services performed during the same session
• Any complications or unexpected findings
• Signature of the performing provider

7. Billing guidelines

When billing for CPT code 58671, it is important to ensure that the procedure performed aligns with the description provided. This code should be reported for laparoscopic procedures involving the occlusion of the oviducts using a device. If only one tube is occluded, modifier 52 should be appended to indicate reduced services. It is also important to review any specific billing guidelines provided by payers to ensure accurate reimbursement.

8. Historical information

CPT code 58671 was added to the Current Procedural Terminology system on January 1, 2000. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient undergoes a laparoscopic procedure for the occlusion of both fallopian tubes using a clip.
2. A provider performs a laparoscopic procedure to occlude the oviducts using a band for a patient seeking permanent sterilization.
3. A laparoscopic procedure is performed to block the fallopian tubes using a Falope ring for a patient who desires permanent contraception.
4. A provider uses a laparoscope and a clip to occlude both fallopian tubes during a laparoscopic procedure for sterilization.