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The CPT® Code 58260 refers to a surgical procedure known as a vaginal hysterectomy, specifically performed on a uterus that weighs 250 grams or less. In this procedure, the physician accesses the uterus through the vaginal canal, which is a less invasive approach compared to abdominal hysterectomy techniques. The process begins with the placement of tenacula, which are surgical instruments used to grasp the cervix, allowing for better visibility and access to the surrounding structures. The vaginal mucosa, which is the lining of the vagina, is then incised around the cervix to facilitate the removal of the uterus. Following the incision, traction is applied to the tenacula to stabilize the cervix while the bladder is carefully separated from the uterus using both blunt and sharp dissection techniques. This step is crucial to avoid injury to the bladder during the procedure. Once the bladder is elevated, the peritoneal vesicouterine fold is incised, allowing access to the cul-de-sac, which is the space behind the uterus. The broad ligament, which supports the uterus, is then exposed, and the uterosacral ligaments are clamped and divided to further free the uterus. The cardinal ligaments, which provide additional support to the uterus, are clamped at the lower uterine segment, incised, and ligated with sutures to prevent bleeding. The lower portion of the broad ligament is also clamped and divided at its attachment to the lower uterine segment. After these steps, the posterior wall of the uterus is grasped, and the uterus is delivered into the vagina. If the procedure involves the removal of the fallopian tubes and ovaries, the tubo-ovarian round ligaments are exposed, clamped, and incised close to the uterine fundus on both sides. The fallopian tubes are then transected, and the round ligaments are doubly ligated. The uterus is subsequently removed, and if the tubes and ovaries are also to be excised, the round ligament is cut and tied bilaterally. Tension is applied to the infundibulopelvic ligament, which is then cut, allowing for the delivery of the tubes and ovaries along with the uterus into the vaginal canal. After the removal of these structures, the anterior vaginal wall is elevated, and the entire length of the broad ligament is inspected to control any bleeding. The peritoneum is then closed, and the vaginal cuff is intentionally left open to allow for drainage of the pelvis. It is important to note that this code is specifically used when only the uterus is removed, while different codes apply when additional structures such as the tubes and ovaries are also excised or when an enterocele repair is performed.
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The procedure coded as CPT® 58260 is indicated for the surgical removal of the uterus in cases where the uterus weighs 250 grams or less. This may include various conditions such as:
The procedure for CPT® 58260 involves several detailed steps to ensure the safe and effective removal of the uterus. The process begins with the placement of tenacula on the cervix, which helps stabilize the area for the surgeon. The next step involves incising the vaginal mucosa around the entire cervix, allowing access to the uterus. Once the incision is made, traction is applied to the tenacula, which aids in separating the bladder from the uterus through both blunt and sharp dissection techniques. This careful dissection is crucial to prevent any damage to the bladder during the procedure.
After the bladder is elevated, the surgeon incises the peritoneal vesicouterine fold, which provides access to the cul-de-sac. The peritoneum is then incised to expose the broad ligament, which supports the uterus. The surgeon proceeds to clamp and divide the uterosacral ligaments, which are essential for uterine support. Following this, the cardinal ligaments are clamped at the lower uterine segment, incised, and ligated with sutures to control any bleeding that may occur during the procedure.
Next, the lower portion of the broad ligament is clamped and divided at its attachment to the lower uterine segment. The posterior wall of the uterus is then grasped, and the uterus is delivered into the vagina. If the procedure includes the removal of the fallopian tubes and ovaries, the surgeon exposes the tubo-ovarian round ligaments, clamps them, and incises them close to the uterine fundus on both sides. The fallopian tubes are transected, and the round ligaments are doubly ligated to ensure proper closure.
Once the uterus is removed, if the tubes and ovaries are also to be excised, the round ligament is cut and tied bilaterally. Tension is applied to the infundibulopelvic ligament, which is then cut, allowing for the delivery of the tubes and ovaries along with the uterus into the vaginal canal. After the removal of these structures, the anterior vaginal wall is elevated, and the entire length of the broad ligament is inspected to control any bleeding. Finally, the peritoneum is closed, and the vaginal cuff is intentionally left open to allow for drainage of the pelvis.
Post-procedure care following a vaginal hysterectomy coded as CPT® 58260 typically involves monitoring for any signs of complications such as excessive bleeding or infection. Patients are usually advised to rest and avoid strenuous activities for a specified period to promote healing. Pain management may be provided as needed, and follow-up appointments are scheduled to ensure proper recovery. The vaginal cuff is left open for drainage, which is an important consideration in the post-operative care plan to prevent fluid accumulation and potential infection.
| Short Descr | VAGINAL HYSTERECTOMY | Medium Descr | VAGINAL HYSTERECTOMY UTERUS 250 GM/< | Long Descr | Vaginal hysterectomy, for uterus 250 g or less; | 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 | Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weight. | 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). | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | GC | This service has been performed in part by a resident under the direction of a teaching physician | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | 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. | 25 | Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service: it may be necessary to indicate that on the day a procedure or service identified by a cpt code was performed, the patient's condition required a significant, separately identifiable e/m service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. a significant, separately identifiable e/m service is defined or substantiated by documentation that satisfies the relevant criteria for the respective e/m service to be reported (see evaluation and management services guidelines for instructions on determining level of e/m service). the e/m service may be prompted by the symptom or condition for which the procedure and/or service was provided. as such, different diagnoses are not required for reporting of the e/m services on the same date. this circumstance may be reported by adding modifier 25 to the appropriate level of e/m service. note: this modifier is not used to report an e/m service that resulted in a decision to perform surgery. see modifier 57 for significant, separately identifiable non-e/m services, see modifier 59. | 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). | 53 | Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) 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). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 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.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 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 | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | CR | Catastrophe/disaster related | GW | Service not related to the hospice patient's terminal condition | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | SG | Ambulatory surgical center (asc) facility service | 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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| 2010-01-01 | Changed | Code description changed. |
| 2007-01-01 | Changed | Code description changed. |
| 2003-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
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