How To Use CPT Code 57110

CPT 57110 describes the complete removal of the vaginal wall, a procedure known as vaginectomy. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 57110?

CPT 57110 is used to describe the surgical procedure of vaginectomy, which involves the complete removal of the vaginal wall. This procedure is typically performed by a healthcare provider to address certain medical conditions or as part of a treatment plan. It is important to note that CPT 57110 specifically refers to the removal of the vaginal wall and does not include other related procedures such as lymphadenectomy or vaginal reconstruction.

2. Official Description

The official description of CPT code 57110 is: ‘Vaginectomy, complete removal of vaginal wall.’

3. Procedure

1. In this procedure, the healthcare provider begins by making an abdominal incision and entering the peritoneal cavity.
2. After exploration, the provider carefully dissects the bladder off the anterior vaginal wall and the rectum off the posterior vaginal wall down to the level of the distal vagina.
3. The provider then releases the ureters from the surrounding tissue and ligaments to ensure they are not cut during the surgery.
4. All ligament supports of the vagina at the level of the pelvic sidewall are cut, allowing the vagina to be freely moveable.
5. The provider clamps and sutures all vascular connections before removing the entire vagina.
6. After irrigating the peritoneal cavity and cauterizing any bleeding, the provider may place closed suction drains.
7. Vaginal reconstruction may be performed at a later time if necessary.

4. Qualifying circumstances

CPT 57110 is typically performed for medical reasons, such as addressing certain conditions or as part of a treatment plan. It is important to consult with a healthcare provider to determine if this procedure is necessary and appropriate for the patient’s specific circumstances. The decision to perform a vaginectomy should be based on a thorough evaluation of the patient’s condition and consideration of alternative treatment options.

5. When to use CPT code 57110

CPT code 57110 should be used when a healthcare provider performs a complete removal of the vaginal wall, known as vaginectomy. It is important to accurately document the procedure and ensure that it aligns with the official description of CPT 57110. This code should not be used for other related procedures, such as lymphadenectomy or vaginal reconstruction, as they have their own specific codes.

6. Documentation requirements

To support a claim for CPT 57110, the healthcare provider must document the following information:

• Reason for performing the vaginectomy
• Details of the procedure, including the approach used and any additional steps taken
• Date of the procedure
• Any complications or unexpected findings
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 57110, it is important to ensure that the procedure performed aligns with the official description of the code. The healthcare provider should accurately document the details of the procedure and any additional steps taken. It is also important to follow any specific billing guidelines provided by insurance companies or regulatory bodies. It is recommended to consult with a coding specialist or billing expert to ensure accurate and appropriate billing for CPT 57110.

8. Historical information

CPT 57110 was added to the Current Procedural Terminology system on January 1, 1990. The code underwent a change on January 1, 2010, with the description being updated to ‘Vaginectomy, complete removal of vaginal wall.’ It is important to stay updated with any changes or updates to the code to ensure accurate coding and billing.

9. Examples

1. A healthcare provider performs a vaginectomy to address a severe case of vaginal cancer.
2. A patient with a history of recurrent vaginal infections undergoes a vaginectomy to alleviate symptoms and improve quality of life.
3. A transgender individual undergoes a vaginectomy as part of their gender-affirming surgery.
4. A patient with a genetic condition that predisposes them to vaginal abnormalities undergoes a vaginectomy to address the associated health risks.
5. A healthcare provider performs a vaginectomy to address a vaginal prolapse that is causing significant discomfort and functional impairment for the patient.
6. A patient with a history of chronic vaginal pain undergoes a vaginectomy as a last resort after other treatment options have been exhausted.
7. A healthcare provider performs a vaginectomy as part of a comprehensive treatment plan for a patient with a rare vaginal malformation.
8. A patient with a history of recurrent vaginal bleeding undergoes a vaginectomy to address the underlying cause of the bleeding.
9. A healthcare provider performs a vaginectomy to remove a large vaginal cyst that is causing pain and discomfort for the patient.
10. A patient with a history of vaginal trauma undergoes a vaginectomy to address the long-term complications and improve overall vaginal health.