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The CPT® Code 58270 refers to a surgical procedure known as a vaginal hysterectomy, specifically for the removal of a uterus weighing 250 grams or less, accompanied by the repair of an enterocele. A vaginal hysterectomy is a minimally invasive surgical technique where the uterus is removed through the vaginal canal rather than through an abdominal incision. This approach is often preferred due to its potential for reduced recovery time and lower risk of complications compared to abdominal hysterectomy. The procedure involves several critical steps, including the careful dissection and separation of surrounding structures such as the bladder and ligaments, to ensure a safe and effective removal of the uterus. The enterocele repair component addresses a condition where a portion of the intestine protrudes into the vaginal wall, necessitating additional surgical intervention to restore normal anatomy and function. The detailed steps of the procedure highlight the complexity and precision required in performing a vaginal hysterectomy with enterocele repair, ensuring that all anatomical structures are handled appropriately to minimize complications and promote healing.
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The procedure described by CPT® Code 58270 is indicated for the following conditions:
The procedure for CPT® Code 58270 involves several detailed steps to ensure the successful removal of the uterus and repair of the enterocele:
Post-procedure care following a vaginal hysterectomy with enterocele repair includes monitoring for any signs of complications such as excessive bleeding or infection. Patients are typically advised to rest and avoid strenuous activities for a specified period to promote healing. Follow-up appointments are essential to assess recovery and ensure that the surgical site is healing properly. Patients may also receive instructions regarding pain management and care for the vaginal cuff, which is left open to facilitate drainage. It is important for patients to adhere to their healthcare provider's recommendations to support optimal recovery and prevent complications.
| Short Descr | VAG HYST W/ENTEROCELE REPAIR | Medium Descr | VAGINAL HYSTERECTOMY 250 GM/< W/RPR ENTEROCELE | Long Descr | Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele | 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 | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1E - Major procedure - hysterctomy | MUE | 1 | CCS Clinical Classification | 124 - Hysterectomy, abdominal and vaginal |
| 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). | 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. | 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.) | 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 | SG | Ambulatory surgical center (asc) facility service |
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| 2007-01-01 | Changed | Code description changed. |
| 2003-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
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