How To Use CPT Code 57106

CPT 57106 describes the partial removal of the vaginal wall, specifically either the upper one third or the lower two thirds. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 57106?

CPT 57106 can be used to describe a surgical procedure in which a portion of the vaginal wall is removed. This code specifically refers to the removal of either the upper one third or the lower two thirds of the vaginal wall. The procedure is typically performed to treat vaginal cancer or severe chronic benign conditions that affect the vaginal canal. It may also be used for biopsies of large vaginal lesions where the presence of cancer is uncertain.

2. Official Description

The official description of CPT code 57106 is: ‘Vaginectomy, partial removal of vaginal wall.’

3. Procedure

1. The patient is positioned in lithotomy position, with knees bent and spread apart using stirrups.
2. The provider administers a general anesthetic to the patient.
3. The provider marks the extent of the planned excision using sutures.
4. To minimize bleeding, the provider injects the area with a vasoconstrictive agent.
5. If the surgery is performed vaginally, the provider makes a circular incision at the lower end of the area to be removed.
6. The provider dissects the vagina off the underlying structures and removes the diseased portion, including margins.
7. Sutures are applied to control bleeding as the procedure progresses.
8. If the surgery is performed abdominally, the provider identifies the vaginal vault and makes an incision over it.
9. The provider separates the rectum from the vagina and the uterosacral ligament, taking care not to injure the ureters.
10. The diseased tissue is excised as described in the vaginal approach procedure.
11. Drains may be placed if the abdominal approach is used.

4. Qualifying circumstances

CPT 57106 is typically performed for the treatment of vaginal cancer or severe chronic benign conditions affecting the vaginal canal. It may also be used for biopsies of large vaginal lesions where the presence of cancer is uncertain. The procedure can be performed via the vaginal or abdominal approach, depending on the specific circumstances and the provider’s judgment.

5. When to use CPT code 57106

CPT code 57106 should be used when a partial removal of the vaginal wall is performed, either the upper one third or the lower two thirds. It is important to accurately document the extent of the excision and the approach used (vaginal or abdominal) to ensure proper coding and billing.

6. Documentation requirements

To support a claim for CPT 57106, the following documentation is typically required:

• Patient’s diagnosis necessitating the partial vaginectomy
• Extent of the planned excision (upper one third or lower two thirds)
• Approach used (vaginal or abdominal)
• Date of the procedure
• Details of the procedure, including any additional steps taken or complications encountered
• Any additional procedures performed concurrently
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 57106, ensure that the documentation supports the partial removal of the vaginal wall and specifies the extent of the excision and the approach used. It is important to accurately report the procedure to ensure proper reimbursement. CPT code 57106 should not be reported with other codes for more extensive vaginectomy procedures, such as radical partial vaginectomy or complete vaginectomy.

8. Historical information

CPT 57106 was added to the Current Procedural Terminology system on January 1, 1999. The code was later revised on January 1, 2010 to clarify the description of the procedure.

9. Examples

1. A patient undergoes a partial vaginectomy to treat vaginal cancer, with the removal of the lower two thirds of the vaginal wall.
2. A provider performs a partial vaginectomy via the abdominal approach to address a severe chronic benign condition affecting the vaginal canal.
3. A biopsy of a large vaginal lesion is performed using CPT 57106 to determine if cancer is present.
4. A patient with suspected vaginal cancer undergoes a partial vaginectomy, with the removal of the upper one third of the vaginal wall.
5. A provider performs a partial vaginectomy to treat a severe chronic benign condition affecting the vaginal canal, removing the lower two thirds of the vaginal wall.
6. A biopsy of a large vaginal lesion is performed using CPT 57106 to rule out the presence of cancer.
7. A patient with vaginal cancer undergoes a partial vaginectomy, with the removal of the upper one third of the vaginal wall.
8. A provider performs a partial vaginectomy via the abdominal approach to address a severe chronic benign condition affecting the vaginal canal.
9. A biopsy of a large vaginal lesion is performed using CPT 57106 to determine if cancer is present.
10. A patient with suspected vaginal cancer undergoes a partial vaginectomy, with the removal of the lower two thirds of the vaginal wall.