How To Use CPT Code 57285

CPT 57285 describes the repair of a paravaginal defect using a vaginal approach, including the repair of a cystocele if necessary. 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 57285?

CPT 57285 is used to describe the surgical repair of a paravaginal defect, which involves the dissection of tissues between the vagina, bladder, and urethra using a vaginal approach. This procedure may also include the repair of a cystocele, a condition where the bladder prolapses into the vagina due to weakened fibrous walls.

2. Official Description

The official description of CPT code 57285 is the following: ‘Paravaginal defect repair (including repair of cystocele, if performed); vaginal approach.’ It is important to note that this code should not be reported in conjunction with codes 51990, 57240, 57260, 57265, or 58267.

3. Procedure

1. The patient is placed in the dorsal lithotomy position and given a general anesthetic.
2. An incision is made in the anterior vaginal wall to access the space of Retzius.
3. The provider then dissects the bladder away from the vaginal tissue and extends this dissection to expose the arcus tendineus fascia pelvis on both sides.
4. Sutures are placed along the side of the vagina through the pubocervical fascia and brought through the obturator internus muscle, which is located just above the arcus tendineus fascia pelvis.
5. The sutures are tied to close the defect, and the fascia is closed.
6. If a cystocele is present, additional sutures may be added to strengthen and close the anterior vaginal wall, providing better support to the bladder.

4. Qualifying circumstances

CPT 57285 is performed on patients with a paravaginal defect, which is a loss of support of the arcus tendineus fascia pelvis. This defect can lead to the prolapse of the bladder and urethra, resulting in conditions such as cystocele or urethrocystocele. The procedure is typically performed by a provider using a vaginal approach.

5. When to use CPT code 57285

CPT code 57285 should be used when a paravaginal defect repair is performed using a vaginal approach. It is important to note that this code should not be reported with codes for bladder or urethral repair procedures, such as the Marshal-Marchetti-Krantz procedure or laparoscopic urethral suspension. Additionally, if the procedure includes an anterior colporrhaphy for cystocele repair, it should not be reported separately with CPT code 57285.

6. Documentation requirements

To support a claim for CPT code 57285, the provider must document the following information:

• The presence of a paravaginal defect and the need for repair
• The use of a vaginal approach for the procedure
• The specific steps taken during the procedure, including the dissection of tissues and closure of the defect
• If applicable, the repair of a cystocele and any additional sutures used
• The date of the procedure and the duration of the surgery
• The patient’s response to the procedure and any post-operative instructions
• The provider’s signature

7. Billing guidelines

When billing for CPT code 57285, ensure that the procedure meets the criteria for a paravaginal defect repair using a vaginal approach. It is important to note that this code should not be reported with certain other codes, as mentioned in the official description. Additionally, if the provider documents weakened or attenuated pubocervical fascia and uses a mesh for reinforcement, the add-on code +57267 should be reported.

8. Historical information

CPT code 57285 was added to the Current Procedural Terminology system on January 1, 2008. There have been no updates to the code since its addition.

9. Examples

1. A provider performs a paravaginal defect repair using a vaginal approach, including the repair of a cystocele, for a patient with pelvic organ prolapse.
2. During a surgical procedure, a provider repairs a paravaginal defect and performs a cystocele repair using a vaginal approach for a patient with bladder prolapse.
3. A patient undergoes a paravaginal defect repair with a vaginal approach to address the loss of support in the arcus tendineus fascia pelvis.
4. A provider performs a paravaginal defect repair using a vaginal approach, including the reinforcement of weakened pubocervical fascia with a mesh, for a patient with recurrent cystocele.
5. During a surgical procedure, a provider repairs a paravaginal defect and performs an anterior colporrhaphy to address the patient’s cystocele and rectocele.
6. A patient undergoes a paravaginal defect repair using a vaginal approach to correct the prolapse of the bladder and urethra.
7. A provider performs a paravaginal defect repair using a vaginal approach, including the repair of a cystocele, for a patient with urinary incontinence.
8. During a surgical procedure, a provider repairs a paravaginal defect and performs a sling operation for stress incontinence using a vaginal approach.
9. A patient undergoes a paravaginal defect repair with a vaginal approach to address the loss of support in the arcus tendineus fascia pelvis and the resulting cystocele.