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The CPT® Code 58291 refers to a surgical procedure known as a vaginal hysterectomy, specifically indicated for the removal of an enlarged uterus weighing greater than 250 grams, along with the removal of the fallopian tubes and/or ovaries. This procedure is typically performed when the uterus is significantly enlarged, which may necessitate the use of morcellation techniques to facilitate its removal in multiple pieces. Morcellation can involve various methods such as hemisection, where the uterus is divided into two halves; intramyometrial coring, which involves removing a core of tissue from the interior of the uterus to reduce its size; or wedge resection, which entails cutting the uterus into smaller segments. The procedure begins with the placement of tenacula on the cervix to provide traction, followed by an incision of the vaginal mucosa around the cervix. The bladder is then carefully separated from the uterus using both blunt and sharp dissection techniques. This meticulous approach allows for the elevation of the bladder to expose the peritoneal vesicouterine fold, which is subsequently incised. The surgical team then exposes the cul-de-sac and incises the peritoneum, ligating the uterine vessels to control bleeding. The morcellation technique is employed to remove the uterus while severing its attachments. As the uterus is exteriorized, the broad ligament becomes visible, and the uterosacral ligaments are clamped and divided. The cardinal ligaments are clamped at the lower uterine segment, incised, and ligated with sutures. The procedure continues with the clamping and division of the lower portion of the broad ligament at its attachment to the lower uterine segment. The tubo-ovarian round ligaments are then exposed, clamped, and incised near the uterine fundus on both sides, followed by the transection of the fallopian tubes. If the tubes and ovaries are to be removed, the round ligaments are cut and tied bilaterally, and the infundibulopelvic ligaments are cut to facilitate the removal of the tubes and ovaries along with the morcellized uterus. The anterior vaginal wall is elevated, and the broad ligament is inspected for bleeding, which is controlled before closing the peritoneum. The vaginal cuff is intentionally left open to allow for drainage of the pelvis. This code is specifically used when both the uterus and the adnexa (tubes and ovaries) are removed, distinguishing it from other related codes that describe variations of the procedure.
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The procedure associated with CPT® Code 58291 is indicated for the following conditions:
The procedure for CPT® Code 58291 involves several detailed steps to ensure the safe and effective removal of the uterus along with the tubes and/or ovaries:
Post-procedure care for patients undergoing CPT® Code 58291 includes monitoring for any signs of complications such as bleeding or infection. Patients are typically advised to rest and may be prescribed pain management medications as needed. Follow-up appointments are essential to assess recovery and address any concerns. The vaginal cuff is intentionally left open to facilitate drainage, and patients should be informed about signs of infection or unusual symptoms that may require immediate medical attention. Recovery time may vary, but patients are generally advised to avoid strenuous activities and sexual intercourse for a specified period as directed by their healthcare provider.
| Short Descr | VAG HYST INCL T/O COMPLEX | Medium Descr | VAG HYST > 250 GM RMVL TUBE&/OVARY | Long Descr | Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or 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) | 2 - Co-surgeons permitted and no documentation required if the two- specialty requirement is met. | 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. | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure 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 |
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| 2011-01-01 | Changed | Short description changed. |
| 2007-01-01 | Changed | Code description changed. |
| 2003-01-01 | Added | First appearance in code book in 2003. |
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