How To Use CPT Code 58953

CPT 58953 describes a specific surgical procedure known as bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy, and radical dissection for debulking. This article will provide an overview of the code, including its official description, the procedure involved, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and similar codes to CPT 58953.

1. What is CPT Code 58953?

CPT 58953 is a code used to describe a surgical procedure that involves the removal of the uterus, cervix, ovaries, fallopian tubes, and omentum. This procedure is performed through an abdominal incision and may also include the radical excision of intraabdominal or peritoneal tumors. It is typically performed to debulk malignant tumors that cannot be completely excised, thereby increasing the effectiveness of radiation or chemotherapy.

2. Official Description

The official description of CPT code 58953 is: ‘Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy, and radical dissection for debulking.’

3. Procedure

1. The patient is placed 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 abdominal wall is dissected until the abdominal cavity is reached.
3. The provider explores the abdomen and collects samples of peritoneal fluid for cytologic examination.
4. The abdominal contents are moved out of the pelvis using a retractor.
5. The uterus, cervix, ovaries, fallopian tubes, and pelvic peritoneum are removed. The provider carefully dissects the ureters off their peritoneal attachments along their entire course within the pelvis.
6. If there are masses on the pelvic peritoneum, the provider removes the peritoneum as part of the radical resection. The goal is to remove all tumor nodules larger than 1 cm found in the abdomen and pelvis.
7. For the omentectomy, the provider makes another small incision in the abdomen and partially or completely removes the thin tissue lining the abdomen near the stomach.
8. All bleeding is controlled, and the abdomen is closed in layers. A suction drain may be placed if necessary.

4. Qualifying circumstances

CPT 58953 is typically performed on patients with malignant tumors that cannot be completely excised. It is important to note that this procedure is considered an inpatient-only (IPO) service according to Medicare guidelines.

5. When to use CPT code 58953

CPT code 58953 should be used when performing a bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy, and radical dissection for debulking. 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 58953, the following documentation is required:

• Patient’s medical history and diagnosis
• Details of the surgical procedure performed, including the specific structures removed
• Any additional procedures or services provided during the same operative session
• Operative report with a description of the surgical technique used
• Pathology report, if applicable
• Any complications or unexpected findings during the procedure
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 58953, it is important to follow the appropriate guidelines. This procedure is typically performed in an inpatient setting and is considered an inpatient-only (IPO) service according to Medicare guidelines. It is important to review the specific billing requirements of the payer to ensure accurate and timely reimbursement.

8. Historical information

CPT code 58953 was added to the Current Procedural Terminology system on January 1, 2002. There have been no updates or changes to the code since its addition. However, it is important to stay updated with any changes in coding guidelines or payer requirements.

9. Examples

1. A patient with ovarian cancer undergoes CPT 58953 to remove the uterus, cervix, ovaries, fallopian tubes, and omentum, as well as perform a radical dissection for debulking.
2. A provider performs CPT 58953 on a patient with advanced endometrial cancer to remove the necessary structures and debulk the tumor.
3. A patient with metastatic abdominal tumors undergoes CPT 58953 to remove the uterus, cervix, ovaries, fallopian tubes, and omentum, as well as perform a radical dissection to improve the effectiveness of subsequent treatments.
4. CPT 58953 is performed on a patient with recurrent ovarian cancer to remove the affected structures and reduce the tumor burden.
5. A provider performs CPT 58953 on a patient with peritoneal carcinomatosis to remove the necessary structures and improve the patient’s response to chemotherapy.
6. A patient with advanced cervical cancer undergoes CPT 58953 to remove the uterus, cervix, ovaries, fallopian tubes, and omentum, as well as perform a radical dissection to improve the effectiveness of radiation therapy.
7. CPT 58953 is performed on a patient with primary peritoneal cancer to remove the affected structures and debulk the tumor.
8. A provider performs CPT 58953 on a patient with recurrent endometrial cancer to remove the necessary structures and reduce the tumor burden.
9. A patient with advanced fallopian tube cancer undergoes CPT 58953 to remove the uterus, cervix, ovaries, fallopian tubes, and omentum, as well as perform a radical dissection to improve the effectiveness of subsequent treatments.
10. CPT 58953 is performed on a patient with recurrent peritoneal cancer to remove the affected structures and improve the patient’s response to chemotherapy.