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The CPT® Code 58280 refers to a surgical procedure known as a vaginal hysterectomy, which involves the removal of the uterus through the vaginal canal. This specific code is used when the procedure includes a total or partial vaginectomy, which is the surgical removal of part or all of the vaginal wall, along with the repair of an enterocele, a type of hernia that occurs when the small intestine protrudes into the vaginal wall. The procedure begins with the placement of tenacula, which are surgical instruments used to grasp the cervix, allowing for better access and visibility during the operation. The vaginal mucosa, or the lining of the vagina, is then incised around the cervix to facilitate the removal of the uterus. During the surgery, careful dissection is performed to separate the bladder from the uterus, ensuring that surrounding structures are preserved. The bladder is elevated to provide access to the peritoneal vesicouterine fold, which is then incised to expose the cul-de-sac. The broad ligament, which supports the uterus, is also exposed and manipulated to allow for the clamping and division of the uterosacral and cardinal ligaments, which are critical for uterine support. Once the uterus is detached, it is delivered into the vagina, and the fallopian tubes are transected. The procedure may also involve the removal of the vaginal wall, with incisions made along both the anterior and posterior aspects, depending on whether a total or partial vaginectomy is performed. The enterocele repair is an integral part of this procedure, where the sac is incised, and the small bowel is repositioned before closing the sac with sutures. This comprehensive approach ensures that both the uterus and any associated conditions, such as an enterocele, are effectively addressed during the surgical intervention.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 58280 is indicated for patients who require a vaginal hysterectomy with total or partial vaginectomy and repair of an enterocele. The specific indications for this procedure may include:
The procedure for CPT® Code 58280 involves several detailed steps to ensure the successful removal of the uterus and the repair of the enterocele. The steps are as follows:
After the completion of the procedure, patients are typically monitored for any immediate complications, including bleeding or infection. Recovery may involve pain management and instructions for activity restrictions to promote healing. Follow-up appointments are essential to assess the surgical site and ensure proper recovery. Patients may also receive guidance on pelvic floor exercises or other rehabilitation measures to support recovery and prevent complications such as pelvic organ prolapse.
| Short Descr | HYSTERECTOMY/REVISE VAGINA | Medium Descr | VAG HYSTER W/TOT/PRTL VAGINECT W/RPR ENTEROCELE | Long Descr | Vaginal hysterectomy, with total or partial vaginectomy; 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 | 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). | 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). | AG | Primary physician | 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 |
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| 2002-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
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