How To Use CPT Code 57268

CPT 57268 describes the repair of an enterocele using a vaginal approach. 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 57268?

CPT 57268 is used to describe the repair of an enterocele, which is a condition where the small bowel pushes through to the vaginal canal. This procedure is performed using a vaginal approach, and it involves repairing the vaginal wall where the enterocele is located.

2. Official Description

The official description of CPT code 57268 is: ‘Repair of enterocele, vaginal approach (separate procedure).’ This code specifically refers to the repair of an enterocele using a vaginal approach, and it should not be reported when performed along with a related procedure in the same anatomic area or through the same incision, orifice, or surgical approach.

3. Procedure

1. The patient is placed in the dorsal lithotomy position, with knees bent and positioned above the hips, and spread apart using stirrups.
2. The provider administers anesthesia and places a Foley catheter to drain the bladder.
3. The provider grasps the vagina over the enterocele with clamps and sizes the boundaries.
4. A midline incision is made through the vaginal fascia over the enterocele.
5. The provider carefully dissects the vaginal tissue away until the enterocele sac is freely mobile.
6. If necessary, a rectal exam may be performed to distinguish the enterocele sac from the rectum.
7. The provider then dissects the enterocele sac from the vagina and the rectum.
8. The sac is explored to ensure that no small bowel or omental adhesions are present.
9. The provider sutures the sac closed and removes any excess vaginal wall.
10. Vaginal packing is inserted to aid in healing.

4. Qualifying circumstances

This procedure is performed on patients with an enterocele, which is a bulging of the small intestines and perineum into the vaginal canal. It is important to note that this code should not be reported when performed along with a related procedure in the same anatomic area or through the same incision, orifice, or surgical approach.

5. When to use CPT code 57268

CPT code 57268 should be used when a provider performs a separate procedure to repair an enterocele using a vaginal approach. It should not be reported when performed along with a related procedure in the same anatomic area or through the same incision, orifice, or surgical approach.

6. Documentation requirements

To support a claim for CPT code 57268, the provider must document the following information:

• Patient’s diagnosis of an enterocele
• Description of the repair procedure performed
• Date of the procedure
• Details of the surgical approach used (vaginal approach)
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 57268, it is important to ensure that the procedure is performed as a separate procedure and not as part of a related procedure. If the provider performs this procedure with an unrelated procedure, modifier 59 (Distinct procedural service) should be appended to the code. However, be sure that the documentation supports the procedure as a separate procedure and not part of some other related procedure. It is important not to confuse modifier 59 with modifier 51, which is used for multiple procedures. Modifier 51 is not appropriate for reporting CPT code 57268.

8. Historical information

CPT code 57268 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 provider performs a separate procedure to repair an enterocele using a vaginal approach.
2. A patient with an enterocele undergoes a vaginal repair procedure to correct the condition.
3. A provider performs a separate procedure to repair an enterocele, which is causing discomfort and other symptoms for the patient.
4. A patient with an enterocele undergoes a surgical procedure to repair the condition using a vaginal approach.
5. A provider performs a separate procedure to repair an enterocele, improving the patient’s quality of life.
6. A patient with an enterocele undergoes a vaginal repair procedure to alleviate symptoms and prevent further complications.
7. A provider performs a separate procedure to repair an enterocele, addressing the patient’s specific needs and concerns.
8. A patient with an enterocele undergoes a surgical procedure to repair the condition, restoring normal anatomy and function.
9. A provider performs a separate procedure to repair an enterocele, ensuring the patient’s comfort and well-being.
10. A patient with an enterocele undergoes a vaginal repair procedure, resulting in improved quality of life.