How To Use CPT Code 57135

CPT 57135 describes the excision of a cyst or tumor in the vaginal wall. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 57135?

CPT 57135 is used to describe the surgical removal of a cyst or tumor in the vaginal wall. This procedure is performed by a healthcare provider and involves excising the entire semisolid material or fully removing the tumor along with supportive healthy tissues surrounding it. The excision is done through an incision made in the vaginal mucosa, and the provider may send a sample of the cyst to the laboratory for examination. Local anesthesia is administered, and the patient is positioned in the dorsal lithotomy position during the procedure.

2. Official Description

The official description of CPT code 57135 is: ‘Excision of vaginal cyst or tumor.’

3. Procedure

1. The healthcare provider administers local anesthesia to the patient.
2. The patient is positioned in the dorsal lithotomy position.
3. The provider cleans the area of the cyst with plain water or dilute vinegar.
4. The provider carefully examines the cyst or tumor area for excision under local anesthesia.
5. An incision is made in the vaginal mucosa over the cyst or around the tumor.
6. The provider excises the whole semisolid material of the cyst or fully removes the vaginal tumor along with supportive healthy tissues around it.
7. A sample of the cyst may be sent to the laboratory for examination.
8. The provider closes the incision with absorbable sutures.
9. The vagina may be packed with bleached cotton cloth.

4. Qualifying circumstances

CPT 57135 is used for the excision of vaginal cysts or tumors. These cysts or tumors can be of various types, such as Gartner’s duct cyst, Bartholin’s cyst, small cysts, or benign tumors. It is important to note that this code should not be used for the drainage of a vaginal cyst. Vaginal tumors are abnormal growths of tissue in the vagina, and they can be primary or secondary vaginal cancer.

5. When to use CPT code 57135

CPT code 57135 should be used when a healthcare provider performs the excision of a vaginal cyst or tumor. It is important to ensure that the excision is done through an incision in the vaginal mucosa and that the entire semisolid material of the cyst or the tumor, along with supportive healthy tissues, is removed. This code should not be used for the drainage of a vaginal cyst.

6. Documentation requirements

To support a claim for CPT 57135, the healthcare provider must document the following information:

• Patient’s diagnosis indicating the presence of a vaginal cyst or tumor
• Details of the excision procedure, including the incision made and the removal of the cyst or tumor
• Use of local anesthesia
• Any additional procedures performed, such as sending a cyst sample to the laboratory
• Details of the closure of the incision with absorbable sutures
• Use of vaginal packing, if applicable

7. Billing guidelines

When billing for CPT 57135, ensure that the excision is performed by a healthcare provider and that the entire semisolid material of the cyst or the tumor, along with supportive healthy tissues, is removed. It is important to note that this code should not be reported for the drainage of a vaginal cyst. There are no specific guidelines regarding reporting CPT 57135 with other codes.

8. Historical information

CPT 57135 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A healthcare provider performs the excision of a vaginal cyst in a patient who presents with symptoms of discomfort and swelling in the vaginal area.
2. During a routine gynecological examination, a healthcare provider identifies a vaginal tumor and performs its excision using CPT code 57135.
3. A patient with a history of vaginal cysts undergoes the excision of a recurrent cyst using CPT code 57135.
4. A healthcare provider performs the excision of a benign vaginal tumor in a patient who has been experiencing abnormal vaginal bleeding.
5. During a surgical procedure for the removal of a vaginal cyst, a healthcare provider discovers a small tumor and performs its excision using CPT code 57135.
6. A patient with a known vaginal tumor undergoes the excision of the tumor to alleviate symptoms and prevent further complications.
7. A healthcare provider performs the excision of a Bartholin’s cyst in a patient who presents with pain and swelling in the vaginal area.
8. During a pelvic examination, a healthcare provider identifies a vaginal tumor and performs its excision using CPT code 57135.
9. A patient with a recurrent vaginal cyst undergoes the excision of the cyst to relieve symptoms and prevent complications.
10. A healthcare provider performs the excision of a small benign vaginal tumor in a patient who has been experiencing discomfort during sexual intercourse.