How To Use CPT Code 58954

CPT 58954 describes the surgical procedure known as bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy, and radical dissection for debulking, including pelvic lymphadenectomy and limited para-aortic lymphadenectomy. This article will provide an overview of CPT 58954, 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 58954?

CPT 58954 is a code used to describe a surgical procedure that involves the removal of the fallopian tubes, ovaries, omentum, uterus, cervix, pelvic lymph nodes, and a limited number of para-aortic lymph nodes. This procedure is performed through an abdominal incision and is typically done to debulk tumors and treat certain gynecological conditions.

2. Official Description

The official description of CPT code 58954 is: ‘Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy.’

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, allowing access to the abdominal cavity.
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 provider then proceeds to remove the uterus, ovaries, fallopian tubes, and pelvic peritoneum.
6. If there are masses on the pelvic peritoneum, the provider removes them as part of the radical resection.
7. Pelvic lymph nodes are examined and removed, followed by samples of lymph nodes over the lower inferior vena cava and abdominal aorta.
8. A separate incision is made for the omentectomy, during which the thin tissue lining the abdomen near the stomach is partially or completely removed.
9. All bleeding is controlled, and the abdomen is closed in layers, with the placement of a suction drain if necessary.

4. Qualifying circumstances

CPT 58954 is typically performed on patients with gynecological conditions that require the removal of the fallopian tubes, ovaries, uterus, and cervix. This procedure is often done to debulk tumors and may involve the removal of pelvic and para-aortic lymph nodes. It is important to note that this procedure is performed through an abdominal incision and requires the expertise of a qualified healthcare professional.

5. When to use CPT code 58954

CPT code 58954 should be used when performing a bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy, and radical dissection for debulking, including pelvic lymphadenectomy and limited para-aortic lymphadenectomy. This code should be used for each instance of this specific surgical procedure.

6. Documentation requirements

To support a claim for CPT 58954, the healthcare professional must document the following information:

• Patient’s diagnosis and the need for the surgical procedure
• Details of the procedure performed, including the removal of specific organs and lymph nodes
• Date of the surgery
• Any complications or additional procedures performed
• Signature of the healthcare professional performing the surgery

7. Billing guidelines

When billing for CPT 58954, it is important to ensure that the procedure meets the criteria outlined in the official description. The surgery should be performed by a qualified healthcare professional and should include the removal of the specified organs and lymph nodes. It is also important to follow any additional guidelines provided by the payer or coding guidelines.

8. Historical information

CPT 58954 was added to the Current Procedural Terminology system on January 1, 2002. In 2017, it was added to the Inpatient Only (IPO) list for Medicare reimbursement.

9. Examples

1. A patient with ovarian cancer undergoes CPT 58954, which includes the removal of the fallopian tubes, ovaries, omentum, uterus, cervix, pelvic lymph nodes, and limited para-aortic lymph nodes.
2. A patient with endometriosis requires a bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy, and radical dissection for debulking, including pelvic lymphadenectomy and limited para-aortic lymphadenectomy, which is coded as CPT 58954.
3. A patient with a large pelvic mass undergoes CPT 58954 to remove the tumor, along with the fallopian tubes, ovaries, omentum, uterus, cervix, pelvic lymph nodes, and limited para-aortic lymph nodes.
4. A patient with uterine cancer requires a total abdominal hysterectomy, bilateral salpingo-oophorectomy, and omentectomy, which is coded as CPT 58954.
5. A patient with advanced ovarian cancer undergoes CPT 58954, which includes the removal of the fallopian tubes, ovaries, omentum, uterus, cervix, pelvic lymph nodes, and limited para-aortic lymph nodes, as well as debulking of tumor nodules.