CPT Knowledgebase - Dec 8, 2022

What is the appropriate code to report a modified radical robotic hysterectomy? Coding instructions provided in several issues of CPT® Assistant (September 2015, March 2019, December 2021's Bonus Questions) state that elements shown in the code descriptor are required to be performed and documented in order to report a specific CPT code. As such, is it still appropriate to report code 58548 when all of the elements in the descriptor are not documented in the operative note? How should variations of the procedure described by code 58548 be reported when components such as "total bilateral pelvic lymphadenectomy," "para-aortic lymph node sampling," or "removal of parametria" are not performed or documented?

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