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The CPT® Code 58540 refers to a surgical procedure known as hysteroplasty, specifically aimed at repairing a uterine anomaly classified as Strassman type. This procedure addresses various congenital malformations of the uterus, which are primarily categorized as Mullerian uterine anomalies. These anomalies arise from disruptions during fetal development when the Mullerian ducts, which are responsible for forming the fallopian tubes, uterus, cervix, and the upper part of the vagina, do not develop properly. The types of uterine anomalies that can be corrected through hysteroplasty include conditions such as unicornuate uterus, where only one horn of the uterus develops; didelphys, characterized by a complete or partial duplication of the uterus, cervix, and/or vagina; bicornuate uterus, which involves a partial division of the uterus; septate uterus, where a fibrous or muscular septum divides the uterine cavity; and arcuate uterus, which is a mild form of uterine anomaly. The surgical approach taken during hysteroplasty is tailored to the specific type of anomaly present. A commonly performed technique is the Strassman metroplasty, which is particularly effective for treating didelphic and bicornuate uterine anomalies. This involves making a transverse incision in the fundus of the uterus, followed by the incision of the myometrial partition to create a single uterine cavity. The procedure is concluded by suturing the incision in a manner that ensures proper healing and functionality of the uterus. Other variations of the procedure may include wedge resections for bicornuate or septate uteri, where specific incisions are made to remove tissue and repair the uterine structure, ultimately aiming to restore normal uterine anatomy and function.
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The procedure of hysteroplasty, specifically coded as CPT® 58540, is indicated for the correction of various Mullerian uterine anomalies. These anomalies can lead to reproductive challenges and may include the following conditions:
The hysteroplasty procedure involves several critical steps tailored to the specific type of uterine anomaly being addressed. The following outlines the procedural steps involved:
Post-procedure care following hysteroplasty involves monitoring the patient for any complications and ensuring proper recovery. Patients may experience some discomfort and are typically advised to rest and avoid strenuous activities for a specified period. Follow-up appointments are essential to assess healing and the success of the procedure. The healthcare provider will provide specific instructions regarding activity restrictions, pain management, and signs of potential complications that should be reported immediately. Additionally, the patient may be counseled on reproductive health and any necessary follow-up treatments or assessments based on the type of uterine anomaly corrected.
| Short Descr | REVISION OF UTERUS | Medium Descr | HYSTEROPLASTY RPR UTERINE ANOMALY | Long Descr | Hysteroplasty, repair of uterine anomaly (Strassman type) | 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) | 0 - Co-surgeons not permitted for this procedure. | 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) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 132 - Other OR therapeutic procedures, female organs |
| 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. | 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 | LT | Left side (used to identify procedures performed on the left side of the body) |
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| Pre-1990 | Added | Code added. |
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