How To Use CPT Code 58900

CPT 58900 describes the procedure for biopsy of the ovary, either unilateral or bilateral, through a vaginal or abdominal approach. 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 58900?

CPT 58900 can be used to describe the procedure for biopsy of the ovary, either unilateral or bilateral. This code is used when a tissue sample is taken from one or both ovaries for diagnostic purposes. The procedure can be performed through a vaginal or abdominal approach, depending on the patient’s specific circumstances.

2. Official Description

The official description of CPT code 58900 is: ‘Biopsy of ovary, unilateral or bilateral (separate procedure).’ It is important to note that for laparoscopic biopsy of the ovary or fallopian tube, a different CPT code, 49321, should be used.

3. Procedure

1. In the vaginal approach, the patient is positioned in the dorsal lithotomy position and a regional anesthetic is administered. The provider inserts a speculum into the vagina and makes a small incision in the vaginal wall. Using biopsy forceps, the provider locates the ovarian lesion and obtains a tissue sample from one or both ovaries. The tissue sample is then sent to the laboratory for examination. If necessary, the provider closes the vaginal wall with a small stitch.
2. In the abdominal approach, the patient is placed in the supine position and a general anesthetic is administered. The provider makes an incision in the lower abdomen, just above the symphysis pubis, and continues to incise through the underlying tissue and peritoneum. The provider examines the abdominal cavity and identifies the ovarian vessels. Using biopsy forceps, the provider obtains a sample of the abnormal tissue from one or both ovaries. The tissue sample is sent to the laboratory for examination. Finally, the provider closes the abdominal incision with sutures.

4. Qualifying circumstances

CPT 58900 is performed on patients who require a biopsy of the ovary for diagnostic purposes. It is typically used when there is a suspected abnormality or lesion in the ovary that needs to be examined. The procedure can be performed on one or both ovaries, depending on the specific circumstances of the patient.

5. When to use CPT code 58900

CPT code 58900 should be used when a biopsy of the ovary, either unilateral or bilateral, is performed. It is important to note that for laparoscopic biopsy of the ovary or fallopian tube, a different CPT code, 49321, should be used. CPT 58900 is specifically for the vaginal or abdominal approach to biopsy the ovary.

6. Documentation requirements

To support a claim for CPT 58900, the provider must document the following information:

• Patient’s diagnosis or suspected abnormality in the ovary
• Approach used for the biopsy (vaginal or abdominal)
• Whether the biopsy was performed on one or both ovaries
• Date of the procedure
• Details of the procedure, including any complications or additional findings
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 58900, it is important to ensure that the procedure was performed on the ovary, either unilateral or bilateral, through a vaginal or abdominal approach. It is also important to use the appropriate CPT code based on the specific circumstances of the patient. Modifier 59, Distinct procedural service, should be used sparingly as it generally does not bypass the bundling edit with other procedures involving the uterus and ovaries.

8. Historical information

CPT 58900 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 patient undergoes a vaginal biopsy of the ovary to investigate a suspected abnormality.
2. A provider performs an abdominal biopsy of both ovaries to diagnose a potential ovarian lesion.
3. A patient with a history of ovarian cysts undergoes a unilateral biopsy of the ovary through the vaginal approach.
4. A provider performs a bilateral biopsy of the ovaries through the abdominal approach to investigate infertility issues.
5. A patient with a family history of ovarian cancer undergoes a unilateral biopsy of the ovary through the vaginal approach for early detection.
6. A provider performs an abdominal biopsy of the ovary to investigate pelvic pain and rule out any abnormalities.
7. A patient with suspected endometriosis undergoes a bilateral biopsy of the ovaries through the vaginal approach.
8. A provider performs a unilateral biopsy of the ovary through the abdominal approach to investigate a suspected tumor.
9. A patient with polycystic ovary syndrome undergoes a bilateral biopsy of the ovaries through the vaginal approach for further evaluation.
10. A provider performs an abdominal biopsy of both ovaries to investigate a potential hormonal imbalance.