How To Use CPT Code 58951

CPT 58951 describes the resection of ovarian, tubal, or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy, along with total abdominal hysterectomy, pelvic and limited para-aortic lymphadenectomy. 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 58951?

CPT 58951 can be used to describe the surgical procedure performed to remove an ovarian, tubal, or primary peritoneal malignancy. This code includes the resection of the fallopian tubes, ovaries, omentum, uterus, cervix, pelvic lymph nodes, and a limited number of para-aortic lymph nodes. The procedure is done through an abdominal incision and is typically performed to treat cancer in these areas.

2. Official Description

The official description of CPT code 58951 is: ‘Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with total abdominal hysterectomy, pelvic and limited para-aortic lymphadenectomy.’

3. Procedure

1. The patient is placed in the supine position and given a general anesthetic.
2. An incision is made on the lower abdomen, extending from above the symphysis pubis to the rib cage.
3. The underlying tissue and peritoneum are incised to access the abdominal cavity.
4. The provider examines and removes the pelvic lymph nodes and exposes the para-aortic lymph nodes, removing a limited portion of the lymph tissue near the aorta.
5. The provider thoroughly examines the abdominal and peritoneal cavity for any spread of the malignant tumor.
6. The malignancy is resected, and the omentum may be partially or completely removed through another small incision in the abdomen.
7. An incision is made to expose the uterine vessels and ligaments, including the infundibulopelvic ligament.
8. The fallopian tubes and ovaries are dissected and removed from the surrounding structures.
9. The provider moves aside the ligaments and vessels from the uterus, ties the vessels completely, and removes the uterus, parametria, cervix, and upper third of the vagina.
10. The provider controls any bleeding and closes the vaginal cuff and abdominal incision with absorbable sutures.

4. Qualifying circumstances

CPT 58951 is performed on patients with ovarian, tubal, or primary peritoneal malignancy. The procedure is typically done as an initial resection and may involve the removal of the fallopian tubes, ovaries, omentum, uterus, cervix, pelvic lymph nodes, and a limited number of para-aortic lymph nodes. It is important to note that this code is specific to the initial resection and should not be used for subsequent procedures or revisions.

5. When to use CPT code 58951

CPT code 58951 should be used when performing the initial resection of ovarian, tubal, or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy, along with total abdominal hysterectomy, pelvic and limited para-aortic lymphadenectomy. 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 58951, the provider must document the following information:

• Patient’s diagnosis of ovarian, tubal, or primary peritoneal malignancy
• Details of the resection procedure, including the removal of specific organs and lymph nodes
• Date of the procedure
• Start and end time of the procedure
• Any additional procedures performed during the same surgical session
• Any complications or unexpected findings during the procedure
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 58951, ensure that the procedure meets the specific criteria outlined in the code description. It is important to note that this code is specific to the initial resection and should not be used for subsequent procedures or revisions. Additionally, consider any additional procedures performed during the same surgical session and report them accordingly. Follow the appropriate coding guidelines and modifiers as required by the payer.

8. Historical information

CPT 58951 was added to the Current Procedural Terminology system on January 1, 1990. There have been several changes to the code description over the years, including the addition of specific details and the inclusion of additional procedures. It is important to stay updated with any changes or revisions to ensure accurate coding and billing.

9. Examples

1. A patient undergoes CPT 58951 for the initial resection of ovarian malignancy, with bilateral salpingo-oophorectomy and omentectomy, along with total abdominal hysterectomy, pelvic and limited para-aortic lymphadenectomy.