2025 CPT code 58960
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Female Genital System Surgery Feed
Laparotomy for staging or restaging ovarian, tubal, or primary peritoneal malignancy (second-look), with or without omentectomy, peritoneal washing, biopsy of abdominal and pelvic peritoneum, diaphragmatic assessment with pelvic and limited para-aortic lymphadenectomy.
Modifiers may be applicable depending on the circumstances of the procedure.Consult the CPT manual for appropriate modifier usage.
Medical necessity for 58960 is established when there is a clinical indication for staging or restaging of ovarian, tubal, or primary peritoneal malignancy, such as suspected recurrence, or in initial staging to guide treatment planning.The procedure must be medically appropriate based on the patient's clinical presentation and relevant diagnostic testing.
The surgeon performs the laparotomy, takes biopsies and washings, removes lymph nodes, and performs an omentectomy (if necessary).The surgeon is responsible for pre-operative assessment, anesthesia administration (or supervision), surgical technique, intraoperative management, and post-operative care.Pathology services are separately billed.
In simple words: This surgery helps doctors check the spread of ovarian, fallopian tube, or peritoneal cancer.The doctor makes an incision in the abdomen to examine the area, take tissue samples, and remove lymph nodes.This helps determine the stage of cancer and whether it has returned after previous treatment.
This procedure involves a laparotomy to determine the stage of cancer in patients with ovarian, fallopian tube, or primary peritoneal malignancy.It's often a "second-look" procedure to assess for recurrence. The procedure includes peritoneal washing and cytologic evaluation, biopsies of the abdominal and pelvic peritoneum, diaphragmatic assessment, and selective removal of pelvic and para-aortic lymph nodes.An omentectomy (partial or complete removal of the omentum) may also be performed. The abdomen is closed in layers after the procedure.
Example 1: A 55-year-old female patient with a history of ovarian cancer undergoes a second-look laparotomy (58960) to assess for recurrence after chemotherapy. The procedure involves peritoneal washings, biopsies of the peritoneum, and lymph node removal.An omentectomy was performed because the omentum was involved.The pathology report confirmed no evidence of recurrent disease., A 48-year-old female patient presents with suspected ovarian cancer.A staging laparotomy (58960) is performed, including peritoneal washings, biopsies, and lymph node dissection.The pathology report indicates stage IIIc ovarian cancer. Appropriate oncology treatment is planned based on the results., A 62-year-old female patient with a history of tubal cancer has a restaging laparotomy (58960) after a period of remission.The procedure includes peritoneal washings, peritonea biopsies, lymph node dissection, and an omentectomy.The pathology report reveals microscopic residual disease.
* Complete history and physical examination.* Preoperative imaging studies (e.g., CT scan, MRI).* Intraoperative findings (e.g., extent of disease, lymph node involvement).* Pathology reports (e.g., cytology, histology).* Operative report with detailed description of the procedure, including the extent of the lymph node dissection and whether an omentectomy was performed.* Postoperative care documentation.
** This procedure is usually performed by a gynecologic oncologist or a gynecologist with expertise in oncologic surgery. Reimbursement may vary based on the payer and the specific details of the procedure.
- Revenue Code: P1G (MAJOR PROCEDURE - OTHER)
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:Gynecologic Oncology, Gynecology
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center