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The CPT® Code 58400 refers to a surgical procedure known as uterine suspension, which may involve the shortening of the round ligaments and/or sacrouterine ligaments. This procedure is classified as a separate procedure, indicating that it can be performed independently of other surgical interventions. Uterine suspension is primarily indicated for conditions that may require stabilization of the uterus, often in the context of pelvic support issues. The procedure is performed through an abdominal incision, allowing the surgeon to access the uterus and associated ligaments directly. During the operation, the surgeon may employ various techniques to shorten the ligaments, which can help in repositioning the uterus and alleviating associated symptoms. Although open uterine suspension was once a common approach, it has largely been supplanted by laparoscopic techniques, which offer benefits such as reduced recovery time and less postoperative pain. The procedure may also be performed in conjunction with a presacral sympathectomy, which is aimed at alleviating pelvic pain by interrupting nerve pathways. Overall, CPT® Code 58400 encapsulates a critical surgical intervention for managing specific gynecological conditions, emphasizing the importance of precise coding for accurate billing and reimbursement.
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The procedure associated with CPT® Code 58400 is indicated for various conditions that necessitate the stabilization of the uterus. The following are explicitly provided indications for performing uterine suspension:
The procedure for CPT® Code 58400 involves several detailed steps to ensure effective uterine suspension. The following outlines the procedural steps:
Post-procedure care following CPT® Code 58400 involves monitoring the patient for any complications and ensuring proper recovery. Patients may experience some discomfort or pain at the incision site, which can be managed with appropriate analgesics. It is essential to provide instructions regarding activity restrictions, particularly avoiding heavy lifting or strenuous activities for a specified period to promote healing. Follow-up appointments should be scheduled to assess the surgical site and the patient's overall recovery progress. Any signs of infection or unusual symptoms should be reported to the healthcare provider promptly.
| Short Descr | SUSPENSION OF UTERUS | Medium Descr | UTERINE SUSPENSION W/WO SHORTENING LIGAMENTS SPX | Long Descr | Uterine suspension, with or without shortening of round ligaments, with or without shortening of sacrouterine ligaments; (separate procedure) | 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) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 132 - Other OR therapeutic procedures, female organs |
| 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). | GC | This service has been performed in part by a resident under the direction of a teaching physician | 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). | 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 |
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| Pre-1990 | Added | Code added. |
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