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Posted By Mary Peabody on 06-09-2020, 19:37:39 in Ob-Gyn
Hello Melanie

A total vaginal hysterectomy with Modified McCall Culdoplasty was performed on a transgender patient. Would we report CPT 58270 if there is no mention of an entercele?
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Posted By Melanie Witt on 06-12-2020, 14:47:25
No, I would not. Preventing vaginal vault prolapse by supporting the vaginal cuff is an essential part of hysterectomy, whether abdominal or vaginal. The McCall culdoplasty procedure is performed to support the vaginal cuff at the time of a vaginal hysterectomy by attaching the uterosacral and cardinal ligaments to the peritoneal surface with suture material such that, when tied, it draws toward the midline, helping to close off the cul-de-sac. This procedure not only supports the vaginal cuff but also closes off the cul-de-sac, thus preventing the formation of an enterocele. As such it would be considered integral to the normal vaginal hysterectomy procedure and is not separately billable.
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