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The CPT® Code 58275 refers to a surgical procedure known as a vaginal hysterectomy, which is performed in conjunction with either a total or partial vaginectomy. This procedure involves the removal of the uterus through the vaginal canal, and it may also include the excision of part or all of the vaginal wall. The process begins with the placement of tenacula, which are surgical instruments used to grasp the cervix, allowing for better access to the surgical site. The vaginal mucosa, which is the lining of the vagina, is then incised around the cervix to facilitate the dissection and removal of surrounding structures. During the procedure, traction is applied to the tenacula to stabilize the cervix, and the bladder is carefully separated from the uterus using both blunt and sharp dissection techniques. This step is crucial to prevent injury to the bladder during the surgery. The bladder is elevated to provide a clear view of the peritoneal vesicouterine fold, which is subsequently incised to access the cul-de-sac, where the peritoneum is also incised. The broad ligament, which supports the uterus, is exposed, and the uterosacral ligaments are clamped and divided to facilitate the removal of the uterus. The cardinal ligaments are clamped at the lower uterine segment, incised, and ligated with sutures to ensure hemostasis. The lower portion of the broad ligament is similarly clamped and divided. Once the posterior uterine wall is grasped, the uterus is delivered into the vagina. The procedure continues with the exposure and clamping of the tubo-ovarian round ligaments, which are then incised close to the uterine fundus on both sides. The fallopian tubes are transected, and the tubo-ovarian ligaments are doubly ligated before the uterus is completely removed. After the uterus is excised, the fallopian tubes are returned to the abdominal cavity, and the surgical site is inspected for any bleeding, which is controlled as necessary. The peritoneum is then closed to complete the internal portion of the procedure. Following the hysterectomy, the vaginectomy is performed, which involves the removal of part or all of the vaginal wall. This is achieved through two longitudinal full-thickness incisions made along the anterior and posterior aspects of the vaginal wall, extending from the top of the vaginal vault to a specified point depending on whether a partial or total vaginectomy is being performed. The incisions allow for the excision of the vaginal wall, and if necessary, vaginal reconstruction with skin grafts may be reported separately. It is important to note that this code (58275) is specifically used when the vaginal hysterectomy and vaginectomy are performed without any enterocele repair, which is a separate procedure that may require a different coding (58280) if performed concurrently.
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The procedure coded as CPT® 58275 is indicated for various conditions that necessitate the removal of the uterus and potentially part or all of the vaginal wall. The specific indications for this procedure include:
The procedure involves several critical steps, each designed to ensure the safe and effective removal of the uterus and vaginal wall. The steps are as follows:
After the completion of the procedure, patients are typically monitored for any immediate complications, such as bleeding or infection. Post-operative care may include pain management, monitoring for signs of infection, and instructions for activity restrictions to promote healing. Patients may also receive guidance on vaginal care and follow-up appointments to ensure proper recovery. The expected recovery time can vary based on individual health factors and the extent of the surgery performed, but patients are generally advised to avoid strenuous activities for a specified period to allow for adequate healing.
| Short Descr | HYSTERECTOMY/REVISE VAGINA | Medium Descr | VAGINAL HYSTERECTOMY W/TOT/PRTL VAGINECTOMY | Long Descr | Vaginal hysterectomy, with total or partial vaginectomy; | 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 |
| 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). | 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). | 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 | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | GC | This service has been performed in part by a resident under the direction of a teaching physician |
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| 2010-01-01 | Changed | Code description changed. |
| 2002-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
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