Oophorectomy / Ovarian Cystectomy (Laparoscopic)
5866158662wRVU: 11.85 — Laparoscopy with fulguration or excision of lesions of ovary, tube, or ligament (cystectomy with ovarian preservation, 11.85 wRVU, 90-day global)58720wRVU: 11.86 — Salpingo-oophorectomy, open (removal of both ovary and tube, 11.86 wRVU, 90-day global)58940wRVU: 8.01 — Oophorectomy, partial or total, unilateral or bilateral, open (8.01 wRVU, 90-day global)58700wRVU: 12.63 — Salpingectomy, complete or partial, open (tube only — 'separate procedure' status, bundled when performed with related pelvic surgery, 12.63 wRVU)
Right [left] [ovarian cyst / adnexal mass / endometrioma / dermoid], [X] cm, [symptomatic / not resolved on surveillance / suspicious features]
Same
Right [left] laparoscopic [oophorectomy / salpingo-oophorectomy / ovarian cystectomy]
[Attending name], MD/DO
[Resident/PA name]
General endotracheal
The patient is a [age]-year-old [female] with a right [left] [X]-cm [ovarian cyst / endometrioma / dermoid / complex adnexal mass] with [symptomatic / persistent / suspicious features on imaging (solid component / septations / color Doppler vascularity)]. Serum CA-125 was [X]. Surgical intervention was recommended. The risks, benefits, and alternatives were discussed and informed consent was obtained.
A [X]-cm [smooth / multiloculated / dermoid] [cyst / mass] was identified on the right [left] ovary. The cyst was [isolated to the ovary / adherent to the bowel / with endometriosis on the ovarian surface]. The contralateral adnexa was [normal]. The uterus was [normal]. [Peritoneal washings were obtained for cytology.] The cyst was removed [intact / with spill of dermoid / chocolate-colored endometriotic fluid. The abdomen was copiously irrigated].
The patient was positioned in the dorsal lithotomy [/ supine] position with Trendelenburg. A [12-mm] umbilical port was placed via [Veress needle / optical trocar / Hasson open technique]. CO₂ insufflation to [15 mmHg]. Two [5-mm] ports were placed in the lower quadrants under direct vision.
[Peritoneal washings were obtained with 50 mL saline and sent for cytology (if malignancy suspected).]
[OVARIAN CYSTECTOMY:]
The ovary was stabilized with atraumatic graspers. A cortical incision was made over the cyst with [scissors / monopolar]. The cyst was dissected from the ovarian stroma in the avascular plane using [blunt dissection / aquadissection]. The cyst was removed intact [or rupture occurred. Copious irrigation was performed]. The ovarian defect was closed with [3-0 Vicryl / bipolar coagulation to hemostasis without suture]. The cyst was placed in a 10-mm retrieval bag.
[OOPHORECTOMY:]
The infundibulopelvic ligament was identified. The ureter was identified at the pelvic brim before ligation. The IP ligament was [coagulated / stapled] and divided. The utero-ovarian ligament and tube were coagulated and divided. The ovary and tube were placed in a 15-mm retrieval bag.
The bag was extracted through the umbilical port [/ extended incision]. The pelvis was irrigated and hemostasis confirmed.
None
Right [left] ovarian cyst [/ ovary ± tube], sent to pathology [and intraoperative frozen section if concern for malignancy]
Minimal
None
The patient was taken to the PACU in stable condition. Ambulation was initiated on postoperative day 1. Diet was advanced as tolerated. Same-day discharge [/ admitted overnight] per clinical course.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Right/Left *** cm ovarian cyst/mass, ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Right/Left laparoscopic oophorectomy/cystectomy
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General
INDICATIONS: .PTAGE-year-old .PTSEX with *** cm right/left ***. CA-125 ***. Surgical intervention indicated. Consent obtained.
FINDINGS: *** cm *** cyst, ***. Contralateral adnexa normal. [Washings sent.] Cyst removed intact/with spill; irrigated.
PROCEDURE:
Lithotomy/supine, Trendelenburg. Umbilical port [Veress needle / optical trocar / Hasson]. CO2 15 mmHg. *** ports. [Washings.] [Cystectomy: cortical incision, avascular plane blunt dissection, cyst removed intact/rupture, ovary closed.] [Oophorectomy: ureter identified, IP ligament coagulated/divided, utero-ovarian/tube divided, specimen in bag.] Bag extracted. Irrigated, hemostatic.
EBL: Minimal
SPECIMENS: *** to pathology [± frozen]
COMPLICATIONS: None
DISPOSITION: PACU. Ambulate POD 1. Same-day DC/admit.
Signed: .ME, .MYDEGREE
.TODAYVariants
Endometrioma (Chocolate Cyst) Cystectomy
The cyst contained thick chocolate-colored fluid consistent with endometrioma. To minimize spill, the cyst was aspirated with a laparoscopic needle prior to incision. The cyst wall was stripped from the ovarian stroma in the avascular plane using traction-countertraction technique, taking care to minimize removal of normal ovarian cortex. Hemostasis of the ovarian defect was achieved with [3-0 Vicryl suture / hemostatic sealant], preserving ovarian cortex. Note: per ESHRE Endometriosis Guidelines (2022) and RCT evidence (Muzii et al.), suture closure is the preferred hemostatic technique for endometrioma cystectomy — bipolar coagulation causes significantly greater AMH decline (~42% vs. ~25% with suture) and should be avoided as the primary hemostatic method; reserve bipolar for focal bleeders only. The abdomen was copiously irrigated to remove all endometriotic fluid. Endometriosis implants on the peritoneum, bowel serosa, and uterosacral ligaments were [excised / fulgurated].
Charting Tips
- Document ureter identification before IP ligament ligation. The ureter runs beneath the infundibulopelvic ligament and is at risk during oophorectomy. Document 'the right ureter was identified at the pelvic brim before ligation of the IP ligament.' This is mandatory for any adnexal surgery.
- Document whether cyst rupture occurred and how it was managed. Cyst spill changes intraoperative management (copious irrigation required) and can affect pathologic assessment of the cyst wall (may obscure malignancy). Document rupture, the response, and the final condition of the abdomen.
- For suspicious masses, document frozen section decision. Intraoperative frozen section guides whether a staging procedure is needed at the same operation. Document the pre-operative suspicion level, whether frozen was sent, and the result if sent.
Billing Tips
- Bill 58661 for laparoscopic removal of adnexal structures (oophorectomy or salpingectomy, 11.07 wRVU, 10-day global). Bill 58662 for laparoscopic excision of ovarian cyst or endometrioma (11.85 wRVU, 90-day global).
- 58661 has a 10-day global period when performed for benign disease. 58662 has a 90-day global. Code selection depends on whether the entire adnexa is removed (58661) or cyst excision with ovarian preservation (58662).
- For open adnexal surgery: oophorectomy alone → 58940 (8.01 wRVU, 90-day global); salpingo-oophorectomy → 58720 (11.86 wRVU, 90-day global); salpingectomy alone → 58700 (12.63 wRVU) — but note 58700 has 'separate procedure' status and is typically bundled when performed with other pelvic surgery. Document open approach or conversion from laparoscopic.
- When oophorectomy is performed at the time of abdominal hysterectomy, use 58150 (which includes 'with or without removal of tube(s)/ovary(s)') — do not separately bill 58940. For vaginal hysterectomy + adnexa, use 58262 (≤250g) or 58291 (>250g). CPT 58152 (21.31 wRVU) is TAH combined with a retropubic bladder neck suspension (Burch/MMK) — it is NOT the TAH+BSO code and should not be used for adnexal removal.
- Frozen section for intraoperative diagnosis of ovarian mass is ordered by the surgeon and results should be documented in the operative note. They affect both operative decision-making and pathology billing.
General coding reference. Verify with your institution’s billing department before submitting claims.