How To Use CPT Code 57200

CPT 57200 describes the procedure of colporrhaphy, which involves suturing a nonobstetrical injury of the vagina. 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 57200?

CPT 57200 is used to describe the surgical repair of a defect or laceration in the wall of the vagina that is not related to childbirth or pregnancy. This procedure involves suturing the injury to promote healing and restore the integrity of the vaginal wall.

2. Official Description

The official description of CPT code 57200 is: ‘Colporrhaphy, suture of injury of vagina (nonobstetrical).’ This code specifically refers to the suturing of a vaginal injury that is not related to childbirth or pregnancy.

3. Procedure

1. The physician administers anesthesia to ensure the patient’s comfort throughout the procedure. This can be local, regional, or general anesthesia.
2. The patient is positioned in the dorsal lithotomy position, lying on her back with her knees bent and spread apart using stirrups.
3. The physician inserts a vaginal instrument to hold open the vagina, allowing better access to the injury site.
4. An incision is made into the vagina to identify the open wound area or fascial defect.
5. The physician carefully sutures the wound defect using appropriate sutures to close the injury and promote healing.
6. If necessary, the physician may remove any excess vaginal skin and then closes the vaginal incision with sutures.

4. Qualifying circumstances

CPT 57200 is performed when there is a nonobstetrical injury or defect in the vaginal wall that requires surgical repair. This procedure is not related to childbirth or pregnancy. The patient may experience symptoms such as pain, discomfort, or compromised vaginal integrity due to the injury. The physician determines the need for colporrhaphy based on the patient’s condition and medical history.

5. When to use CPT code 57200

CPT code 57200 should be used when a physician performs a colporrhaphy to suture a nonobstetrical injury of the vagina. This code is not appropriate for injuries related to childbirth or pregnancy. It is important to accurately document the nature of the injury and the need for surgical repair to support the use of this code.

6. Documentation requirements

To support a claim for CPT 57200, the physician must document the following information:

• Description of the nonobstetrical injury or defect in the vaginal wall
• Type of anesthesia administered
• Date of the procedure
• Details of the surgical technique used, including any modifications or additional procedures performed
• Any complications or unexpected findings during the procedure
• Postoperative care instructions and follow-up plans
• Signature of the performing physician

7. Billing guidelines

When billing for CPT 57200, ensure that the procedure performed is a nonobstetrical colporrhaphy. It is important to accurately document the nature of the injury and the need for surgical repair. CPT code 57200 should not be reported with other codes unless additional procedures or services were performed during the same session. It is crucial to follow the specific guidelines provided by the payer and use appropriate modifiers if necessary.

8. Historical information

CPT 57200 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient presents with a nonobstetrical vaginal injury resulting from a fall. The physician performs a colporrhaphy to suture the injury and promote healing.
2. A patient experiences a vaginal laceration during sexual intercourse. The physician performs a colporrhaphy to repair the injury and restore vaginal integrity.
3. A patient undergoes a gynecological procedure that inadvertently causes a vaginal injury. The physician performs a colporrhaphy to close the wound and ensure proper healing.
4. A patient presents with a nonobstetrical vaginal defect that is causing discomfort and affecting daily activities. The physician performs a colporrhaphy to repair the defect and improve the patient’s quality of life.
5. A patient undergoes a biopsy that results in a nonobstetrical vaginal injury. The physician performs a colporrhaphy to suture the injury and prevent further complications.
6. A patient experiences a nonobstetrical vaginal injury due to a medical device. The physician performs a colporrhaphy to repair the injury and ensure proper healing.
7. A patient presents with a nonobstetrical vaginal injury resulting from a motor vehicle accident. The physician performs a colporrhaphy to suture the injury and promote healing.
8. A patient undergoes a surgical procedure that causes a nonobstetrical vaginal injury. The physician performs a colporrhaphy to repair the injury and restore vaginal integrity.
9. A patient experiences a nonobstetrical vaginal laceration during a physical activity. The physician performs a colporrhaphy to close the wound and ensure proper healing.
10. A patient presents with a nonobstetrical vaginal defect that is causing discomfort and affecting sexual function. The physician performs a colporrhaphy to repair the defect and improve the patient’s quality of life.