Question

This 47-year-old female was taken to surgery for treatment of fibroids. She underwent a vaginal hysterectomy with salpingo-oophorectomy. The uterus weighed 250 grams; ovaries and tubes were normal in appearance. The patient is discharged to home in good condition and given instructions on postoperative care and follow-up. She will be seen in the clinic in one week and will call the office for any problems in the meantime.

What is the CPT code(s)?

Modifiers if appropriate?

Answer 1

CPT code is defined as Current Procedural Terminology. It set of medical code maintained by the American Medical Association .The CPT code set describes the medical, surgical, and diagnostic services undergone by a patient. It is designed in such a way to communicate uniform information about medical services and procedures among the surgeon, doctors , coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes.
Each procedure is given its own unique five digit code that can be identifed by the health insurance companies to under what type of care was provided to the patient.

Eg of CPT code for total hysterectomy for uterus 250g or less is 58570.

Modifier - as the name suggests a modifier is used to modify a service, procedure or an item under certain conditions for appropriate reimbursement.It can add information or change the description according to the physician documentation to give more specificity for the service or procedure rendered.CPT code modifiers are usually a two-digit codes that are linked to the CPT which provide description of the evaluation and management about the procedures performed during the office visit.Code modifiers is used to help further describe a procedure code without changing its definition.