How To Use CPT Code 58952

CPT 58952 describes the resection of ovarian, tubal, or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy, including radical dissection for debulking. 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 58952?

CPT 58952 can be used to describe the surgical procedure performed to remove ovarian, tubal, or primary peritoneal malignancy. This includes the removal of the fallopian tubes, ovaries, and omentum. The procedure may also involve a radical excision of intra-abdominal or retroperitoneal tumors. It is important to note that this code is specifically for the initial resection of the malignancy.

2. Official Description

The official description of CPT code 58952 is: ‘Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with radical dissection for debulking (i.e., radical excision or destruction, intra-abdominal or retroperitoneal tumors).’ It is important to note that there are additional codes available for the resection of recurrent ovarian, tubal, primary peritoneal, or uterine malignancy.

3. Procedure

1. The patient is positioned in the supine position and administered a general anesthetic.
2. An abdominal incision is made from the symphysis pubis to the rib cage, and the peritoneal cavity is entered.
3. Cytologic washings and subdiaphragmatic scrapings are taken.
4. The provider explores the abdomen and pelvis to assess the extent of the malignancy.
5. Bilateral salpingo-oophorectomy is performed by dissecting the pelvic sidewalls, ureters, and sigmoid colon from the tumors on the ovaries or fallopian tubes. The infundibulopelvic ligaments are incised, and the ovaries are removed.
6. If there are masses on the pelvic peritoneum, the provider proceeds with the radical resection, attempting to remove all tumor nodules larger than 1 cm in the abdomen and pelvis.
7. An additional incision is made in the abdomen for the omentectomy, which involves the removal of part or all of the omentum.
8. All bleeding is controlled, and the abdomen is closed in layers.

4. Qualifying circumstances

CPT 58952 is performed on patients with ovarian, tubal, or primary peritoneal malignancy. The procedure is indicated for the initial resection of the malignancy and may involve the removal of the fallopian tubes, ovaries, and omentum. The provider may also perform a radical dissection for debulking, which involves the excision or destruction of intra-abdominal or retroperitoneal tumors.

5. When to use CPT code 58952

CPT code 58952 should be used when the provider is performing the initial resection of ovarian, tubal, or primary peritoneal malignancy. It is important to note that this code is not appropriate for the resection of recurrent malignancy. For recurrent cases, different codes, such as 58957 or 58958, should be used.

6. Documentation requirements

To support a claim for CPT 58952, the provider must document the following information:

• Patient’s diagnosis of ovarian, tubal, or primary peritoneal malignancy
• Details of the procedure, including the removal of fallopian tubes, ovaries, and omentum
• Extent of the malignancy assessed during exploration of the abdomen and pelvis
• Specific steps taken during the bilateral salpingo-oophorectomy and radical resection
• Details of the omentectomy, including whether it was partial or complete
• Control of bleeding and closure of the abdomen

7. Billing guidelines

When billing for CPT 58952, ensure that the procedure meets the criteria for the initial resection of ovarian, tubal, or primary peritoneal malignancy. It is important to note that this code should not be reported for recurrent cases. Additionally, consider any specific guidelines provided by payers or Medicare regarding the use of this code. It is also important to accurately report any additional procedures or services performed during the same encounter.

8. Historical information

CPT 58952 was added to the Current Procedural Terminology system on January 1, 1990. Since its addition, there have been several changes to the code, including updates to the description and inclusion in the Inpatient Only (IPO) list for Medicare.

9. Examples

1. A provider performs CPT 58952 to resect ovarian malignancy, removing the fallopian tubes, ovaries, and omentum, along with a radical dissection for debulking.
2. During the procedure, the provider discovers tubal malignancy and performs CPT 58952 to remove the fallopian tubes, ovaries, and omentum, along with a radical dissection for debulking.
3. A patient presents with primary peritoneal malignancy, and the provider performs CPT 58952 to resect the malignancy, removing the fallopian tubes, ovaries, and omentum, along with a radical dissection for debulking.