How To Use CPT Code 58956

CPT 58956 describes the surgical procedure known as bilateral salpingo-oophorectomy with total omentectomy and total abdominal hysterectomy for malignancy. This article will provide an overview of CPT code 58956, including its official description, the procedure involved, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 58956?

CPT 58956 is a code used to describe a surgical procedure that involves the removal of the uterus, cervix, ovaries, fallopian tubes, and the entire omentum through an abdominal incision. This procedure is performed when there is a diagnosis of malignancy in the patient.

2. Official Description

The official description of CPT code 58956 is: ‘Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy for malignancy.’

3. Procedure

1. The patient is positioned in the supine position and administered a general anesthetic.
2. An abdominal incision is made, extending from just above the symphysis pubis to the rib cage.
3. The underlying tissue and peritoneum are incised to expose the uterine vessels, ligaments, and infundibulopelvic ligament.
4. The fallopian tubes and ovaries are dissected and removed from the surrounding structures.
5. The omentum is excised by freeing it from the transverse colon and removing it from the greater curvature of the stomach or the left and inferior border of the stomach up to the splenic hilum.
6. The vessels around the uterus are tied completely to prevent bleeding.
7. The top portion of the vagina is incised, and the uterus, parametria, cervix, and upper third of the vagina are removed.
8. Any bleeding is controlled, and the vaginal cuff is closed.
9. The abdominal incision is closed with absorbable sutures.

4. Qualifying circumstances

CPT 58956 is performed when there is a diagnosis of malignancy in the patient. It is important to note that CPT 58956 should not be reported in conjunction with other specific codes listed in the notes section.

5. When to use CPT code 58956

CPT code 58956 should be used when performing a bilateral salpingo-oophorectomy with total omentectomy and total abdominal hysterectomy for malignancy. It should not be used in conjunction with other specific codes listed in the notes section.

6. Documentation requirements

To support a claim for CPT 58956, the following documentation is required:

• Diagnosis of malignancy
• Details of the surgical procedure performed
• Date of the procedure
• Start and end time of the procedure
• Any complications or additional procedures performed
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 58956, ensure that the procedure meets the criteria for malignancy. It is important to note that CPT 58956 should not be reported in conjunction with other specific codes listed in the notes section. Follow the appropriate billing guidelines and modifiers as required by the payer.

8. Historical information

CPT 58956 was added to the Current Procedural Terminology system on January 1, 2005. It has not undergone any updates since its addition. In 2017, it was added to the Inpatient Only (IPO) list for Medicare.

9. Examples

1. A patient diagnosed with ovarian cancer undergoes a bilateral salpingo-oophorectomy with total omentectomy and total abdominal hysterectomy using CPT code 58956.
2. A patient with endometrial cancer requires a surgical procedure involving the removal of the uterus, cervix, ovaries, fallopian tubes, and omentum. CPT code 58956 is used for this procedure.
3. A woman diagnosed with cervical cancer undergoes a bilateral salpingo-oophorectomy with total omentectomy and total abdominal hysterectomy using CPT code 58956.
4. A patient with fallopian tube cancer requires a surgical procedure involving the removal of the fallopian tubes, ovaries, uterus, cervix, and omentum. CPT code 58956 is used for this procedure.
5. A woman diagnosed with uterine cancer undergoes a bilateral salpingo-oophorectomy with total omentectomy and total abdominal hysterectomy using CPT code 58956.
6. A patient with ovarian cancer requires a surgical procedure involving the removal of the ovaries, fallopian tubes, uterus, cervix, and omentum. CPT code 58956 is used for this procedure.
7. A woman diagnosed with endometrial cancer undergoes a bilateral salpingo-oophorectomy with total omentectomy and total abdominal hysterectomy using CPT code 58956.
8. A patient with cervical cancer requires a surgical procedure involving the removal of the cervix, uterus, fallopian tubes, ovaries, and omentum. CPT code 58956 is used for this procedure.
9. A woman diagnosed with fallopian tube cancer undergoes a bilateral salpingo-oophorectomy with total omentectomy and total abdominal hysterectomy using CPT code 58956.
10. A patient with uterine cancer requires a surgical procedure involving the removal of the uterus, cervix, fallopian tubes, ovaries, and omentum. CPT code 58956 is used for this procedure.