How To Use CPT Code 57156

CPT 57156 describes the insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy. 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 57156?

CPT 57156 can be used to describe the insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy. This code is used when a healthcare provider fits and places a device into the vaginal canal that will hold radioactive material. The procedure is performed prior to treatment with radiation.

2. Official Description

The official description of CPT code 57156 is: ‘Insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy.’

3. Procedure

1. The healthcare provider places the patient in a lithotomy position and performs a complete pelvic examination.
2. A Foley catheter is inserted into the patient’s bladder and a rectal tube is placed in the rectum.
3. Retractors are used in the vagina to visualize the vaginal cuff.
4. The provider dilates the vagina and releases any post-radiation adhesions if applicable.
5. The largest possible size device is determined to accommodate the patient’s anatomy.
6. A vaginal cylinder in the appropriate width and length is assembled and inserted into the vagina to check for fit and stability.
7. X-rays are taken to confirm the placement of the vaginal device.
8. The base plate of the cylinder is attached to the end of the procedure table and locked in place.
9. The patient is then transferred to the radiation suite for further treatment.

4. Qualifying circumstances

Patients eligible for CPT 57156 are those who require brachytherapy, a form of radiotherapy where a radiation source is placed inside or next to the area requiring treatment. The procedure is typically performed after a hysterectomy for cancer to reduce the chances of the cancer spreading to the upper vagina. The provider must use a vaginal radiation afterloading apparatus for clinical brachytherapy.

5. When to use CPT code 57156

CPT code 57156 should be used when a healthcare provider inserts a vaginal radiation afterloading apparatus for clinical brachytherapy. It is important to note that the removal of the vaginal device is included in payment for its placement.

6. Documentation requirements

To support a claim for CPT 57156, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for brachytherapy
• Details of the procedure, including the use of a vaginal radiation afterloading apparatus
• Date and time of the procedure
• Confirmation of placement through X-rays
• Any additional relevant information or findings

7. Billing guidelines

When billing for CPT 57156, ensure that the procedure involves the insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy. It is important to follow the specific guidelines and requirements set by the payer. Additionally, consider any bundling or unbundling rules that may apply to the procedure.

8. Historical information

CPT 57156 was added to the Current Procedural Terminology system on January 1, 2011. There have been no updates to the code since its addition.

9. Examples

1. A healthcare provider inserts a vaginal radiation afterloading apparatus for clinical brachytherapy in a patient with cervical cancer.
2. During a brachytherapy session, a provider places a vaginal device to deliver radiation treatment for endometrial cancer.
3. A patient undergoes the insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy as part of their treatment for vaginal cancer.
4. A healthcare provider performs the placement of a vaginal radiation afterloading apparatus for clinical brachytherapy in a patient with vulvar cancer.
5. During a brachytherapy procedure, a provider inserts a vaginal device to deliver radiation treatment for vaginal vault cancer.
6. A patient receives the insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy as part of their treatment for recurrent gynecologic cancer.
7. A healthcare provider performs the placement of a vaginal radiation afterloading apparatus for clinical brachytherapy in a patient with vaginal intraepithelial neoplasia.
8. During a brachytherapy session, a provider inserts a vaginal device to deliver radiation treatment for vaginal melanoma.
9. A patient undergoes the insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy as part of their treatment for vaginal sarcoma.
10. A healthcare provider performs the placement of a vaginal radiation afterloading apparatus for clinical brachytherapy in a patient with vaginal adenocarcinoma.