How To Use CPT Code 57265

CPT 57265 describes a surgical procedure that involves the repair of weak vaginal walls and the support of structures such as the bladder, rectum, and small bowel. 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 57265?

CPT 57265 is a code used to describe a surgical procedure that aims to repair weak vaginal walls and provide support to structures such as the bladder, rectum, and small bowel. This procedure is typically performed through a vaginal approach and may include the repair of an enterocele, which occurs when the small intestines and perineum protrude into the vaginal canal. In some cases, a cystourethroscopy, which is an examination of the bladder and urethra using a lighted instrument, may also be performed.

2. Official Description

The official description of CPT code 57265 is: ‘Combined anteroposterior colporrhaphy, including cystourethroscopy, when performed; with enterocele repair.’ It is important to note that this code should not be reported in conjunction with code 52000.

3. Procedure

1. The patient is administered anesthesia and placed in the dorsal lithotomy position.
2. The provider makes an incision into the anterior vaginal skin to expose the damaged pubocervical fascia, which supports the bladder and urethra.
3. Using sutures, the provider plicates the fascia in the midline to strengthen it.
4. The weak edges of the deep vaginal wall are identified and sutured to each other, raising the bladder and forming a strong wall.
5. Excess vaginal skin is removed, and the vaginal incision is closed with dissolving stitches.
6. For the posterior repair, the provider makes an incision in the posterior vaginal wall and plicates the fascia, bringing the edges together and suturing them.
7. The provider performs further dissection to locate the enterocele sac and sutures it closed high in the pelvis to eliminate it.
8. Excess peritoneum is excised, and the anterior and posterior portions of the vaginal apex are closed with sutures.
9. A cystourethroscopy may be performed to ensure the repair has not injured the bladder and urethra.
10. If perineorrhaphy is performed, the provider also repairs the levator and perineal muscles and adds vaginal packing.

4. Qualifying circumstances

CPT 57265 is typically performed on patients with weak vaginal walls and conditions such as cystocele (bladder prolapse), rectocele (rectal tissue bulging into the vagina), and enterocele (small intestines and perineum protruding into the vaginal canal). The procedure is intended to provide support and repair these structures. It is important to note that CPT 57265 should not be reported with code 52000.

5. When to use CPT code 57265

CPT code 57265 should be used when a provider performs a combined anteroposterior colporrhaphy, including enterocele repair, with or without cystourethroscopy. It is important to ensure that the procedure meets the specific criteria outlined in the code description. This code should not be reported with code 52000.

6. Documentation requirements

To support a claim for CPT 57265, the provider must document the following information:

• Patient’s diagnosis and the need for the surgical repair
• Details of the procedure performed, including the repair of weak vaginal walls, enterocele repair, and cystourethroscopy if applicable
• Date of the procedure
• Any additional procedures performed, such as perineorrhaphy
• Any complications or unexpected findings
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 57265, ensure that the procedure meets the specific criteria outlined in the code description. It is important to note that this code should not be reported with code 52000. Pay attention to any additional guidelines provided by payers or coding authorities.

8. Historical information

CPT 57265 was added to the Current Procedural Terminology system on January 1, 1990. The code was later updated on January 1, 2018, with a change in the description to specify the repair of an enterocele.

9. Examples

1. A patient undergoes combined anteroposterior colporrhaphy with enterocele repair to address a cystocele and rectocele.
2. A provider performs a combined anteroposterior colporrhaphy with enterocele repair and cystourethroscopy to repair a cystocele and assess the bladder and urethra.
3. A patient undergoes combined anteroposterior colporrhaphy with enterocele repair and perineorrhaphy to address a rectocele and strengthen the perineal muscles.
4. A provider performs a combined anteroposterior colporrhaphy with enterocele repair and cystourethroscopy to repair a urethrocele and assess the bladder and urethra.
5. A patient undergoes combined anteroposterior colporrhaphy with enterocele repair to address a cystocele and rectocele, without the need for cystourethroscopy.
6. A provider performs a combined anteroposterior colporrhaphy with enterocele repair and perineorrhaphy to address a rectocele and strengthen the perineal muscles, without the need for cystourethroscopy.