2025 CPT code 58285
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Female Genital System Surgery Feed
Radical vaginal hysterectomy (Schauta type operation).
Modifiers may be applicable depending on the circumstances of the surgery. This requires referencing specific payer guidelines and CPT modifier guidelines. For example, modifier 58 may apply if this procedure is performed as a staged procedure related to another service. Modifier 22 may be applied in cases of increased procedural service.
Medical necessity for a radical vaginal hysterectomy is established by a confirmed diagnosis of cervical cancer that requires surgical intervention.The procedure's extent is determined by the stage of cancer and the patient's overall health.
The surgeon performs the radical vaginal hysterectomy. An anesthesiologist or CRNA may administer anesthesia.Nursing staff assists with patient positioning, monitoring, and instrumentation. Pathology services are also involved in examining the removed tissues.
In simple words: This surgery removes the uterus, fallopian tubes, ovaries, and part of the vagina through the vagina. It's done to treat cervical cancer. The doctor makes incisions to remove the organs, and then stitches the area closed.
This procedure involves the removal of the uterus, fallopian tubes, ovaries, parametrium (including uterosacral, cardinal, broad, and round ligaments), and the upper third of the vagina.It's typically performed to treat cervical cancer. The patient is placed in the dorsal lithotomy position under general anesthesia.The procedure may begin with a circular incision in the cervix or an incision in the posterior vaginal wall. Ligaments are incised, the bladder is freed, uterine arteries are clamped and incised, and the broad ligaments are elevated to release ovaries and round ligaments. The uterus, cervix, fallopian tubes, and ovaries are removed.Ureters are freed, and remaining parametrium is dissected. A vaginectomy is performed with vessel-constricting agents to minimize bleeding, followed by closure of incisions and the vaginal cuff.
Example 1: A 50-year-old female patient is diagnosed with stage IB cervical cancer.A radical vaginal hysterectomy (58285) is performed to remove the cancer and surrounding tissue., A 45-year-old female patient with locally advanced cervical cancer undergoes a radical vaginal hysterectomy (58285) as part of a multi-modality treatment plan that may include radiation and/or chemotherapy., A 60-year-old female patient with recurrent cervical cancer after prior treatment is considered for a radical vaginal hysterectomy (58285), although surgical feasibility needs assessment before proceeding.
Complete medical history, physical examination, imaging studies (e.g., MRI, CT, PET), pathology report confirming the diagnosis and staging of cervical cancer, operative report detailing the procedure and findings, and any relevant post-operative pathology reports.
** This code represents a major surgical procedure requiring specialized surgical skills and expertise in gynecologic oncology.Preoperative and postoperative management should be appropriately documented.This procedure typically has a significant recovery period. Individual payer policies may have additional requirements and limitations. Always consult the most current coding guidelines and payer policies before submitting claims.
- Revenue Code: P1E (MAJOR PROCEDURE - HYSTERECTOMY)
- RVU: This information requires access to a specific fee schedule and may vary based on payer and location.
- Global Days: Further information regarding global surgical days for this procedure is needed.This requires referencing current payer specific guidelines.
- Payment Status: Active
- Modifier TC rule: This procedure does not typically have a technical component (TC) modifier. The entire procedure is usually considered a single professional service.
- Fee Schedule: Historical fee schedule data requires access to specific payer fee schedules and may vary significantly based on location and year.
- Specialties:Gynecologic Oncology, Obstetrics and Gynecology
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center