How To Use CPT Code 57230

CPT 57230 describes the plastic repair of a urethrocele, which occurs when the urethra prolapses into the vagina. 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 57230?

CPT 57230 is used to describe the plastic repair of a urethrocele, a condition where the urethra protrudes into the vagina. This code is used when a physician performs a surgical procedure to repair the torn or loose tissue in the urethra, pushing it back into its normal location. The procedure is typically done using a vaginal approach, and a Foley catheter may be inserted at the end of the surgery.

2. Official Description

The official description of CPT code 57230 is: ‘Plastic repair of urethrocele.’

3. Procedure

1. The patient is administered anesthesia and placed in a dorsal lithotomy position.
2. The physician makes an incision in the anterior vaginal wall over the prolapsed area.
3. The torn or loose tissue in the urethra is sutured to provide support and push the urethra back into its normal location.
4. The vaginal wall is closed, and a Foley catheter may be inserted.

4. Qualifying circumstances

CPT 57230 is performed when a patient has a urethrocele, which often accompanies a cystocele. The procedure is typically done by a physician and requires a vaginal approach. The patient must have a torn or loose tissue in the urethra that needs repair.

5. When to use CPT code 57230

CPT code 57230 should be used when a physician performs a plastic repair of a urethrocele. It is important to note that if the urethrocele occurs with a cystocele, code 57230 would be bundled as part of code 57240 for the anterior colporrhaphy.

6. Documentation requirements

To support a claim for CPT 57230, the physician must document the following information:

• Patient’s diagnosis of urethrocele
• Details of the procedure performed, including the approach used
• Date of the procedure
• Any additional procedures performed, such as anterior colporrhaphy
• Insertion of a Foley catheter, if applicable
• Signature of the performing physician

7. Billing guidelines

When billing for CPT 57230, ensure that the procedure is performed by a physician and that the documentation supports the use of this code. It is important to note that if the urethrocele occurs with a cystocele, code 57230 would be bundled as part of code 57240 for the anterior colporrhaphy.

8. Historical information

CPT 57230 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 physician performs a plastic repair of a urethrocele for a patient with a torn urethral tissue.
2. A patient undergoes a surgical procedure to push the prolapsed urethra back into its normal location.
3. A physician repairs the loose tissue in the urethra to provide support and alleviate symptoms.
4. A patient with a urethrocele undergoes a plastic repair to improve urinary function.
5. A physician performs a vaginal approach to repair the torn tissue in the urethra.
6. A patient with a urethrocele undergoes surgery to correct the prolapse and restore normal anatomy.
7. A physician sutures the torn tissue in the urethra to provide support and prevent further prolapse.
8. A plastic repair of a urethrocele is performed to alleviate discomfort and improve quality of life for the patient.
9. A patient undergoes a surgical procedure to push the urethra back into its normal location and restore proper urinary function.
10. A physician repairs the torn tissue in the urethra to prevent complications and improve the patient’s overall health.