How To Use CPT Code 57260

CPT 57260 is a code for combined anteroposterior colporrhaphy, including cystourethroscopy when performed, and this article will cover its description, procedure, qualifying circumstances, usage, documentation requirements, billing guidelines, historical information, similar codes, and examples.

1. What is CPT 57260?

CPT 57260 is a medical procedure code used to describe a combined anteroposterior colporrhaphy, which is a surgical repair of both the anterior and posterior vaginal walls. This procedure is performed to correct issues with the bladder prolapsing into the vaginal canal and also into the rectum. Cystourethroscopy may or may not be performed during this procedure.

2. 57260 CPT code description

The official description of CPT code 57260 is: “Combined anteroposterior colporrhaphy, including cystourethroscopy, when performed.”

3. Procedure

The 57260 procedure involves the following steps:

1. Administration of anesthesia and positioning of the patient in the dorsal lithotomy position.
2. Incision into the anterior vaginal skin to expose the damaged pubocervical fascia, which supports the bladder and urethra.
3. Plication of the fascia in the midline using delayed absorbable or permanent sutures.
4. Identification of the weak edges of the deep vaginal wall and suturing the strong tissue next to the edges to each other, raising the bladder and forming a strong wall below this.
5. Removal of excess vaginal skin and closure of the vaginal incision with dissolving stitches.
6. Rectal exam to check for the extent of the rectocele.
7. Incision in the posterior vaginal wall from the top of the vagina to the levator muscles.
8. Plication of the fascia and suturing of the edges together, including some of the levator muscle in the repair.
9. Removal of excess vaginal wall tissue.
10. Possible performance of cystourethroscopy to visualize the bladder and urethra and ensure the repair has not injured these structures.
11. When perineorrhaphy is performed, repair of the levator and perineal muscles and addition of vaginal packing.

4. Qualifying circumstances

Patients eligible to receive CPT code 57260 services are those experiencing problems with the bladder prolapsing into the vaginal canal and also into the rectum. This condition can cause discomfort, pain, and urinary incontinence. The procedure is typically recommended for patients who have not responded to conservative treatments such as pelvic floor exercises, pessary use, or hormonal therapy.

5. When to use CPT code 57260

It is appropriate to bill the 57260 CPT code when a provider performs a combined anteroposterior colporrhaphy to repair both the anterior and posterior vaginal walls due to bladder and rectal prolapse. The code can be used regardless of whether cystourethroscopy is performed during the procedure.

6. Documentation requirements

To support a claim for CPT 57260, the following information should be documented:

• Patient’s medical history and physical examination findings, including symptoms and failed conservative treatments.
• Indication for the procedure, such as bladder and rectal prolapse.
• Details of the surgical procedure, including the steps performed, materials used, and any complications encountered.
• Postoperative care instructions and follow-up plan.
• Outcome of the procedure, including any improvements in the patient’s symptoms.

7. Billing guidelines

When billing for CPT code 57260, it is important to follow the appropriate guidelines and rules. Do not report 57260 in conjunction with 52000, as this code represents a separate cystourethroscopy procedure. Ensure that all required documentation is included in the patient’s medical record to support the claim. Additionally, be aware of any payer-specific requirements or guidelines that may apply to the billing of this code.

8. Historical information

CPT 57260 was added to the Current Procedural Terminology system on January 1, 1990. There have been changes to the code descriptor over the years, with the most recent change occurring on January 1, 2018.

9. Similar codes to CPT 57260

Five similar codes to CPT 57260 and how they differentiate are:

• CPT 57240: Anterior colporrhaphy only, without the posterior repair.
• CPT 57250: Posterior colporrhaphy only, without the anterior repair.
• CPT 57265: Combined anteroposterior colporrhaphy with enterocele repair, which includes the repair of an enterocele in addition to the anterior and posterior repairs.
• CPT 57282: Colpocleisis, which is a procedure to close off the vaginal canal, typically performed in elderly patients who are not candidates for other prolapse repair procedures.
• CPT 57283: Colpocleisis with enterocele repair, which includes the closure of the vaginal canal and repair of an enterocele.

10. Examples

Here are 10 detailed examples of CPT code 57260 procedures:

1. A 55-year-old woman with symptomatic bladder and rectal prolapse who has failed conservative treatments undergoes a combined anteroposterior colporrhaphy with cystourethroscopy.
2. A 60-year-old woman with a history of multiple vaginal deliveries presents with discomfort and urinary incontinence due to bladder and rectal prolapse, and undergoes CPT 57260 procedure without cystourethroscopy.
3. A 65-year-old woman with a large anterior and posterior vaginal wall prolapse undergoes a combined anteroposterior colporrhaphy with perineorrhaphy and cystourethroscopy.
4. A 70-year-old woman with a history of hysterectomy and symptomatic bladder and rectal prolapse undergoes CPT 57260 procedure with cystourethroscopy to ensure no injury to the bladder and urethra.
5. A 58-year-old woman with a recurrent anterior and posterior vaginal wall prolapse after a previous repair undergoes a combined anteroposterior colporrhaphy without cystourethroscopy.
6. A 62-year-old woman with symptomatic bladder and rectal prolapse and a history of pelvic radiation therapy undergoes CPT 57260 procedure with cystourethroscopy to assess the bladder and urethra.
7. A 67-year-old woman with a large anterior and posterior vaginal wall prolapse and a history of mesh erosion undergoes a combined anteroposterior colporrhaphy with mesh removal and cystourethroscopy.
8. A 72-year-old woman with symptomatic bladder and rectal prolapse and a history of multiple pelvic surgeries undergoes CPT 57260 procedure without cystourethroscopy.
9. A 59-year-old woman with a symptomatic anterior and posterior vaginal wall prolapse and a history of stress urinary incontinence undergoes a combined anteroposterior colporrhaphy with a midurethral sling placement and cystourethroscopy.
10. A 64-year-old woman with a large anterior and posterior vaginal wall prolapse and a history of chronic constipation undergoes a combined anteroposterior colporrhaphy with perineorrhaphy and cystourethroscopy.