2025 CPT code 58800
(Active) Effective Date: N/A Revision Date: N/A Surgical Procedures on the Female Genital System - Incision Procedures on the Ovary Surgery Feed
Drainage of ovarian cyst(s), unilateral or bilateral (separate procedure); vaginal approach.
Modifiers 59 (Distinct Procedural Service), 78 (Unplanned Return to the Operating/Procedure Room), and others may be applicable depending on the specific circumstances of the procedure and payer requirements.Appropriate documentation is essential to support the use of modifiers.
Medical necessity is established when the ovarian cyst(s) cause significant symptoms (e.g., pain, pressure) or potential complications (e.g., torsion, rupture). The procedure is medically necessary to alleviate symptoms or prevent complications.
The physician's responsibilities include patient positioning, administering anesthesia, making the incision, draining the cyst(s), and suturing as necessary.If ultrasound guidance is used, the physician must also interpret the ultrasound images.
- Surgery
- 58800 falls under the broader category of Incision Procedures on the Ovary within the Female Genital System section of CPT codes.
In simple words: This procedure removes fluid from one or more ovarian cysts through a small incision in the vagina.A needle is used to drain the fluid, sometimes with the help of ultrasound imaging to guide the needle.
This procedure involves the drainage of one or more ovarian cysts from one or both ovaries using a vaginal approach. The patient is placed in the dorsal lithotomy position, and a regional anesthetic is administered.A small incision is made into the vaginal canal, and a needle is inserted to drain the fluid from the cyst(s).Ultrasound guidance may be used to assist in needle placement. After complete drainage, the needle is removed, and a suture may be placed at the site as needed.
Example 1: A 35-year-old female presents with symptoms of a large ovarian cyst.A vaginal ultrasound confirms the presence of a large, fluid-filled cyst.The physician performs a vaginal aspiration of the cyst, utilizing ultrasound guidance to precisely place the needle., A 42-year-old female presents with multiple bilateral ovarian cysts detected on a pelvic exam and confirmed via ultrasound.The physician performs a vaginal approach to drain the multiple cysts on both ovaries., A 28-year-old female experiences acute pelvic pain and is found to have a complex ovarian cyst.After initial assessment, the physician chooses a vaginal approach with aspiration using ultrasound guidance to drain the cyst.Following the procedure, a small suture is required to control bleeding at the puncture site.
* Detailed history and physical examination documenting the patient's symptoms and findings.* Pre-operative imaging (e.g., ultrasound) confirming the presence and characteristics of the ovarian cyst(s).* Intraoperative notes detailing the procedure performed, including the approach (vaginal), the number of cysts drained, and the use of any guidance techniques (e.g., ultrasound).* Post-operative notes documenting the patient's recovery and any complications.* Anesthesia records.
** The use of ultrasound guidance is becoming increasingly common for this procedure and should be documented and coded appropriately.The number of cysts drained and whether they are unilateral or bilateral should be clearly noted in the documentation.
- Revenue Code: P1G (MAJOR PROCEDURE - OTHER)
- RVU: RVUs vary depending on geographic location and other factors. Consult a relevant fee schedule or pricing database for specific RVU values and reimbursement rates.
- Global Days: The global surgical period for 58800 is not explicitly defined and may vary depending on payer policies.Consider local guidelines or payer-specific information.
- Payment Status: Active
- Modifier TC rule: No TC modifier is applicable to this code as it represents the entire procedure.
- Fee Schedule: Historical fee schedules vary significantly by location, payer, and year.Consult historical fee data specific to your geographic location and payer for accurate information.
- Specialties:Obstetrics and Gynecology
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center