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Official Description

Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy for malignancy

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 58956 involves a comprehensive surgical intervention known as a bilateral salpingo-oophorectomy with total omentectomy and total abdominal hysterectomy, specifically performed for malignancy. In simpler terms, this procedure entails the surgical removal of both ovaries and fallopian tubes (bilateral salpingo-oophorectomy), the complete removal of the omentum (total omentectomy), and the total removal of the uterus and cervix (total abdominal hysterectomy). This complex operation is typically indicated in cases where malignancy is present, necessitating the removal of reproductive organs and surrounding tissues to prevent the spread of cancer. The surgery is performed through an abdominal incision, allowing the surgeon to access the pelvic and abdominal cavities effectively. The detailed steps of the procedure involve careful dissection and ligation of blood vessels, ensuring that all affected tissues are removed while minimizing damage to surrounding structures. This meticulous approach is crucial for achieving optimal surgical outcomes and addressing the malignancy effectively.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure described by CPT® Code 58956 is indicated for patients diagnosed with malignancy affecting the reproductive organs. The following conditions may warrant this surgical intervention:

  • Malignant Tumors - Presence of cancerous growths in the ovaries, fallopian tubes, uterus, or surrounding tissues.
  • Advanced Stage Cancer - Cases where the malignancy has progressed to a stage that necessitates extensive surgical removal of affected organs to prevent further spread.
  • Recurrent Cancer - Situations where cancer has recurred after previous treatments, requiring aggressive surgical management.

2. Procedure

The surgical procedure for CPT® Code 58956 involves several critical steps, each performed with precision to ensure the effective removal of malignant tissues:

  • Incision and Exposure - The procedure begins with an incision made in the abdomen, allowing the surgeon to expose the anterior surface of the uterus. This access is crucial for the subsequent steps of the surgery.
  • Peritoneal Incision - The peritoneum at the cervicovesical fold is incised to facilitate access to the pelvic organs. This step is essential for the dissection of surrounding tissues.
  • Blunt Dissection - Blunt dissection is employed to carefully expose the broad ligament, round ligament, and fallopian tubes, ensuring that surrounding structures are preserved as much as possible.
  • Broad Ligament Incision - An incision is made in the exposed broad ligament, allowing visualization of the ovarian vessels, which are then suture ligated to control blood flow.
  • Plicating the Broad Ligament - The cut edges of the broad ligament are plicated with mattress sutures to secure the area and prevent bleeding.
  • Dissection of Ovaries and Tubes - The fallopian tubes and ovaries are meticulously dissected free from surrounding tissues, ensuring complete removal of the affected organs.
  • Clamping and Dividing Round Ligaments - The round ligaments are clamped and divided, followed by suture ligation of the associated blood vessels bilaterally.
  • Bladder Dissection - The cervix is palpated to ascertain the position of the bladder, which is then dissected off the uterus, continuing the dissection down to the vaginal wall.
  • Uterine Vessel Management - The posterior aspect of the uterus is inspected, and the uterine vessels are exposed, clamped, divided, and suture ligated to facilitate the removal of the uterus.
  • Cervical and Vaginal Separation - The posterior cervical peritoneum is incised, and the incision is extended around the cervix. The vaginal wall is incised, allowing for the separation of the cervix from the vagina.
  • Removal of Uterus and Ovaries - The uterus and cervix are removed along with the ovaries and fallopian tubes, ensuring that all malignant tissues are excised.
  • Omentum Removal - The omentum is freed from the transverse colon and the greater curvature of the stomach up to the splenic hilum, and subsequently removed from the surgical site.
  • Surgical Site Inspection - The surgical site is carefully inspected to confirm that all visible metastatic disease has been removed, which is critical for the success of the procedure.
  • Bleeding Control and Closure - Any bleeding is controlled, the abdominal wound is irrigated, and the incision is closed with sutures to complete the procedure.

3. Post-Procedure

After the completion of the procedure, patients typically require careful monitoring for any complications. Post-operative care may include pain management, monitoring for signs of infection, and ensuring proper recovery of bodily functions. Patients may also need follow-up appointments to assess healing and discuss any further treatment options related to the malignancy. The surgical site should be kept clean and dry, and any sutures will be removed during follow-up visits as per the surgeon's instructions. Recovery time may vary based on individual health factors and the extent of the surgery performed.

Short Descr BSO OMENTECTOMY W/TAH
Medium Descr BSO W/TOT OMENTECTOMY & HYSTERECTOMY MALIGNANC
Long Descr Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy for malignancy
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) 2 - 150% payment adjustment 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

This is a primary code that can be used with these additional add-on codes.

96547 Add On Code MPFS Status: Active Code APC N Intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) procedure, including separate incision(s) and closure, when performed; first 60 minutes (List separately in addition to code for primary procedure)
96548 Add On Code MPFS Status: Active Code APC N Intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) procedure, including separate incision(s) and closure, when performed; each additional 30 minutes (List separately in addition to code for primary procedure)
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).
52 Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient 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).
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).
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
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.
62 Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate.
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).
AG Primary physician
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
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)
CR Catastrophe/disaster related
GC This service has been performed in part by a resident under the direction of a teaching physician
Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study
Date
Action
Notes
2013-01-01 Changed Medium Descriptor changed.
2011-01-01 Changed Short description changed.
2005-01-01 Added First appearance in code book in 2005.
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