How To Use CPT Code 57023

CPT 57023 describes the procedure of incision and drainage of a vaginal hematoma in non-obstetrical patients. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 57023?

CPT 57023 is used to describe the incision and drainage of a vaginal hematoma in non-obstetrical patients. This procedure is performed when a patient develops a hematoma in the vaginal wall after trauma or spontaneously, unrelated to pregnancy or the postpartum period. The provider makes an incision in the vaginal mucosa over the hematoma, drains the hematoma, and may place a drain for continued drainage. The procedure is typically performed under general anesthesia, with the patient in the dorsal lithotomy position.

2. Official Description

The official description of CPT code 57023 is: ‘Incision and drainage of vaginal hematoma; non-obstetrical (eg, post-trauma, spontaneous bleeding)’. This code specifically applies to the incision and drainage of vaginal hematomas in non-obstetrical patients, such as those who have experienced trauma or spontaneous bleeding.

3. Procedure

1. The patient is appropriately prepped and placed in the dorsal lithotomy position.
2. A speculum is inserted into the vagina to facilitate inspection of the hematoma.
3. The provider cleans the perineum and vagina with an antiseptic solution.
4. An incision is made in the vaginal mucosa over the hematoma.
5. The hematoma is drained, and any bleeding vessels are tied with sutures.
6. The cavity is irrigated, and a drain may be placed for continued drainage.
7. The incised area is closed with sutures, and the vagina is packed with gauze.

4. Qualifying circumstances

CPT 57023 is used for non-obstetrical patients who develop vaginal hematomas after trauma or spontaneous bleeding. It is important to note that this code is not applicable to hematomas that occur during pregnancy or the postpartum period. The procedure must be performed by a qualified healthcare provider and is typically done under general anesthesia.

5. When to use CPT code 57023

CPT code 57023 should be used when a non-obstetrical patient requires an incision and drainage procedure for a vaginal hematoma. It is important to ensure that the patient’s condition meets the qualifying circumstances for this code and that the procedure is performed by a qualified healthcare provider. If the procedure is performed on an obstetrical or postpartum patient, CPT code 57022 should be used instead.

6. Documentation requirements

To support a claim for CPT 57023, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for incision and drainage of a vaginal hematoma
• Details of the procedure, including the incision site, drainage, and any additional interventions performed
• Date of the procedure
• Start and end time of the procedure
• Any complications or unexpected findings
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 57023, ensure that the procedure is performed on a non-obstetrical patient and meets the qualifying circumstances. It is important to follow the specific documentation requirements and include all necessary information on the claim. Additionally, be aware of any specific guidelines or modifiers that may apply to the billing of this code.

8. Historical information

CPT 57023 was added to the Current Procedural Terminology system on January 1, 2001. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient presents with a vaginal hematoma following a traumatic injury. The healthcare provider performs an incision and drainage procedure to alleviate the hematoma and promote healing.
2. A non-obstetrical patient develops a spontaneous vaginal hematoma. The healthcare provider performs an incision and drainage procedure to relieve the hematoma and prevent further complications.
3. After a non-obstetrical patient undergoes a surgical procedure, they develop a vaginal hematoma. The healthcare provider performs an incision and drainage procedure to address the hematoma and promote healing.
4. A patient experiences spontaneous bleeding in the vaginal area, resulting in a hematoma. The healthcare provider performs an incision and drainage procedure to treat the hematoma and prevent infection.
5. Following a non-obstetrical patient’s vaginal trauma, a hematoma forms. The healthcare provider performs an incision and drainage procedure to alleviate the hematoma and promote proper healing.
6. A non-obstetrical patient presents with a vaginal hematoma of unknown origin. The healthcare provider performs an incision and drainage procedure to address the hematoma and prevent further complications.
7. After a non-obstetrical patient undergoes a medical procedure, they develop a vaginal hematoma. The healthcare provider performs an incision and drainage procedure to treat the hematoma and promote healing.
8. A patient experiences spontaneous bleeding in the vaginal area, resulting in the formation of a hematoma. The healthcare provider performs an incision and drainage procedure to alleviate the hematoma and prevent infection.
9. Following a non-obstetrical patient’s vaginal trauma, a hematoma develops. The healthcare provider performs an incision and drainage procedure to address the hematoma and promote proper healing.
10. A non-obstetrical patient presents with a vaginal hematoma of unknown origin. The healthcare provider performs an incision and drainage procedure to treat the hematoma and prevent further complications.