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The procedure described by CPT® Code 57530 refers to a trachelectomy, also known as a cervicectomy, which involves the surgical amputation of the cervix. This procedure is typically performed using a vaginal approach, where the surgeon carefully dissects the surrounding anatomical spaces, including the paravesical, rectovaginal, and vesicovaginal areas. The surgical technique requires the clamping and division of the cardinal and uterosacral ligaments, which are essential for supporting the uterus. Additionally, the uterovesical ligament, located distal to the ureter, is transected to facilitate the removal of the cervix. During the procedure, the vaginal branch of the uterine artery is ligated to control blood flow, and the cervix is transected at its junction with the uterine isthmus. In cases where the patient is younger and desires to preserve fertility, the surgeon may create a new cervical os. To maintain uterine patency, a catheter is inserted and sutured to this new cervical os. Furthermore, a suture is placed around the lower uterine segment to prevent cervical incompetence, which could lead to complications in future pregnancies. The diseased cervix is excised along with the upper third of the vagina, and the proximal vaginal cuff is sutured to either the new cervical os or the remaining uterine body. In instances where an abdominal approach is utilized, the procedure begins with an incision in the abdomen, followed by the ligation of the uterine vessels at their origins. The uterus is then transected at the level of the internal os, and the cervix is removed along with the parametria and the upper third of the vagina. Finally, the proximal vaginal margins are sutured to the uterine body to ensure proper healing and anatomical integrity. This procedure is significant for patients with specific gynecological conditions, and it requires careful consideration of surgical technique and patient outcomes.
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The trachelectomy (cervicectomy) procedure, represented by CPT® Code 57530, is indicated for specific gynecological conditions that necessitate the removal of the cervix while preserving the uterus. The following are the primary indications for this surgical intervention:
The trachelectomy procedure involves several critical steps, which are outlined as follows:
After the trachelectomy procedure, patients typically require careful monitoring and follow-up care. Post-operative care may include pain management, monitoring for signs of infection, and ensuring proper healing of the surgical site. Patients may also need to be educated about potential complications, such as cervical incompetence or changes in menstrual patterns. Follow-up appointments are essential to assess recovery and discuss any concerns regarding future pregnancies, as the procedure may impact reproductive health. It is crucial for patients to adhere to their post-operative care plan and attend all scheduled follow-up visits to ensure optimal outcomes.
| Short Descr | REMOVAL OF CERVIX | Medium Descr | TRACHELECTOMY CERVICECTOMY AMP CERVIX SPX | Long Descr | Trachelectomy (cervicectomy), amputation of cervix (separate procedure) | 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) | 0 - 150% payment adjustment for bilateral procedures 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 | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 125 - Other excision of cervix and uterus |
| 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). | 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. | 54 | Surgical care only: when 1 physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number. | 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). | 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 | GW | Service not related to the hospice patient's terminal condition | 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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| Pre-1990 | Added | Code added. |
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