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The CPT® Code 58180 refers to a surgical procedure known as a supracervical abdominal hysterectomy, also commonly referred to as a subtotal hysterectomy. This procedure involves the removal of the uterus while leaving the cervix intact. The surgery can be performed with or without the removal of the fallopian tubes and/or ovaries, depending on the specific clinical situation and the physician's assessment. During the procedure, the surgeon makes an incision in the abdomen to access the uterus. The anterior surface of the uterus is exposed, and the peritoneum, which is the lining of the abdominal cavity, is incised to allow for further access. Blunt dissection techniques are employed to carefully expose the broad ligament, round ligament, and fallopian tubes. If the decision is made to remove the fallopian tubes and/or ovaries, the surgeon will make an incision in the broad ligament to visualize and ligate the ovarian vessels. The procedure involves meticulous dissection to free the fallopian tubes and ovaries from surrounding tissues, ensuring that blood vessels are clamped and ligated appropriately. The cervix is palpated to ascertain its position relative to the bladder, and the posterior aspect of the uterus is inspected to confirm that there are no adhesions to the rectum. The uterine vessels are then clamped, divided, and ligated, allowing for the separation and removal of the uterus while preserving the cervix. Finally, sutures are placed to suspend the cervix, which is then covered with peritoneum, and the surgical site is thoroughly inspected before closing the abdominal incision. This procedure is typically indicated for various gynecological conditions and is performed with the goal of alleviating symptoms while preserving the cervix for potential future health considerations.
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The supracervical abdominal hysterectomy (CPT® Code 58180) is indicated for a variety of gynecological conditions. The following are explicitly provided indications for this procedure:
The procedure for a supracervical abdominal hysterectomy involves several detailed steps, which are outlined as follows:
After the supracervical abdominal hysterectomy, patients typically require monitoring for any immediate postoperative complications. Expected recovery includes managing pain and monitoring for signs of infection at the surgical site. Patients may be advised to avoid heavy lifting and strenuous activities for a specified period to promote healing. Follow-up appointments are essential to assess recovery progress and address any concerns that may arise. The healthcare provider will provide specific instructions regarding activity restrictions, medication management, and signs of complications that should prompt immediate medical attention.
| Short Descr | PARTIAL HYSTERECTOMY | Medium Descr | SUPRACERVICAL ABDL HYSTER W/WO RMVL TUBE OVARY | Long Descr | Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s) | 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 | Inpatient Procedures, not paid under OPPS | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1E - Major procedure - hysterctomy | MUE | 1 | CCS Clinical Classification | 124 - Hysterectomy, abdominal and vaginal |
| 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. | 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). | 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. | 62 | Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 81 | Minimum assistant surgeon: minimum surgical assistant services are identified by adding modifier 81 to the usual procedure number. | 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 | CR | Catastrophe/disaster related | 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 |
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| Pre-1990 | Added | Code added. |
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