How To Use CPT Code 57288

CPT 57288 is a surgical procedure code for treating stress incontinence using a sling made of fascia or synthetic material. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 57288.

1. What is CPT 57288?

CPT 57288 is a surgical procedure code used to describe the placement of a sling, made of either fascia or synthetic material, to support the urethra and treat urinary stress incontinence. The procedure can be performed abdominally or vaginally, depending on the type of sling used.

2. 57288 CPT code description

The official description of CPT code 57288 is: “Sling operation for stress incontinence (eg, fascia or synthetic)”

3. Procedure

The CPT 57288 procedure involves the following steps:

1. Administration of anesthesia and positioning of the patient in either a dorsal lithotomy or supine position.
2. Accessing the pelvic area through an abdominal or vaginal approach.
3. Placement of a sling, made of fascia or synthetic material, under the urethra and securing it to the abdominal wall and pelvic bone, adjusting for correct tension.
4. Selection of the sling type, which can be a transvaginal sling (such as a Monarc® subfascial hammock, transobturator tape (TOT), tension-free vaginal tape (TVT), or a pubocervical sling).
5. Performing a cystoscopy to ensure the sling is not compromising the bladder.
6. Placement of a catheter for 24 hours, which is removed when the patient can urinate with better control.

4. Qualifying circumstances

Patients eligible to receive CPT 57288 services are those diagnosed with urinary stress incontinence who have not responded to conservative treatments such as pelvic floor exercises, medication, or lifestyle changes. The procedure is typically recommended for patients with moderate to severe stress incontinence, where the condition significantly impacts their quality of life.

5. When to use CPT code 57288

It is appropriate to bill CPT 57288 when a provider performs a sling operation for stress incontinence using fascia or synthetic material. The procedure should be performed only after conservative treatments have failed, and the patient’s condition warrants surgical intervention.

6. Documentation requirements

To support a claim for CPT 57288, the following information should be documented:

• Patient’s medical history and diagnosis of stress incontinence.
• Conservative treatments attempted and their outcomes.
• Indication for surgical intervention and the chosen sling procedure.
• Details of the surgical procedure, including anesthesia, approach, sling type, and any complications.
• Postoperative care, including cystoscopy results and catheter placement.
• Follow-up appointments and patient’s progress after the procedure.

7. Billing guidelines

When billing for CPT 57288, it is important to follow the appropriate guidelines and rules. Cystoscopy is always bundled with a sling procedure and should not be billed separately. For laparoscopic approaches, use CPT code 51992 instead of CPT 57288.

8. Historical information

CPT 57288 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Similar codes to CPT 57288

Five similar codes to CPT 57288 and how they differentiate from CPT 57288 are:

• CPT 57260: This code is used for combined anteroposterior colporrhaphy, which is a different procedure for treating pelvic organ prolapse.
• CPT 57265: This code is for a combined anteroposterior with enterocele repair, which addresses both pelvic organ prolapse and enterocele.
• CPT 57267: This code is for the insertion of a mesh or other prosthesis for repair of pelvic floor dysfunction, which is a broader category of procedures.
• CPT 57282: This code is for colposuspension, which is another procedure for treating stress incontinence but involves suspending the vagina rather than using a sling.
• CPT 51992: This code is for a laparoscopic sling operation, which is a different approach to the sling procedure for stress incontinence.

10. Examples

Here are 10 detailed examples of CPT code 57288 procedures:

1. A 45-year-old female with severe stress incontinence undergoes a transvaginal sling procedure using a synthetic mesh sling.
2. A 55-year-old female with moderate stress incontinence undergoes a pubocervical sling procedure using a strip of her own abdominal fascia.
3. A 60-year-old female with stress incontinence undergoes a tension-free vaginal tape (TVT) procedure.
4. A 50-year-old female with stress incontinence undergoes a transobturator tape (TOT) procedure using the outside-in technique.
5. A 48-year-old female with stress incontinence undergoes a transobturator tape (TOT) procedure using the inside-out technique.
6. A 52-year-old female with stress incontinence undergoes a Monarc® subfascial hammock procedure.
7. A 57-year-old female with stress incontinence undergoes a pubovaginal sling procedure using a strip of her own abdominal fascia.
8. A 63-year-old female with stress incontinence undergoes a transvaginal sling procedure using a synthetic mesh sling, accessed abdominally.
9. A 47-year-old female with stress incontinence undergoes a tension-free vaginal tape (TVT) procedure, accessed vaginally.
10. A 59-year-old female with stress incontinence undergoes a pubocervical sling procedure using a synthetic mesh sling, accessed abdominally.