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The procedure described by CPT® Code 58925 refers to an ovarian cystectomy, which can be performed on one (unilateral) or both (bilateral) ovaries. An ovarian cyst is defined as a fluid-filled sac or pouch that develops on the ovary, which may contain either liquid, semi-solid, or solid material. The surgical approach typically involves an abdominal incision, specifically a suprapubic incision, which is made through the skin and subcutaneous tissue to access the ovaries. During the procedure, the surgeon carefully dissects the cyst from the ovary, ensuring that the cyst wall remains intact to prevent any spillage of its contents. If the cyst is particularly large, the surgeon may first decompress it by puncturing and draining its contents before proceeding with the dissection. The cyst and its contents are collected for laboratory analysis, which is separately reportable. The procedure concludes with the closure of the abdomen in layers, ensuring proper healing and recovery.
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The procedure of ovarian cystectomy is indicated for various conditions related to ovarian cysts. The following are the explicitly provided indications for performing this procedure:
The ovarian cystectomy procedure involves several detailed steps to ensure the safe and effective removal of the cyst. The following procedural steps are outlined:
Post-procedure care following an ovarian cystectomy typically involves monitoring the patient for any immediate complications, such as bleeding or infection. Patients may experience some discomfort or pain at the incision site, which can be managed with appropriate analgesics. Recovery time may vary depending on whether the procedure was unilateral or bilateral, but patients are generally advised to avoid strenuous activities for a specified period to allow for proper healing. Follow-up appointments may be scheduled to assess recovery and discuss the results of the laboratory analysis of the cyst.
| Short Descr | REMOVAL OF OVARIAN CYST(S) | Medium Descr | OVARIAN CYSTECTOMY UNI/BI | Long Descr | Ovarian cystectomy, unilateral or bilateral | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 2 - 150% payment adjustment does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 120 - Other operations on ovary |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AG | Primary physician | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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