How To Use CPT Code 57289

CPT 57289 describes a procedure known as the Pereyra procedure, which involves repairing the vaginal wall to treat both a cystocele and stress urinary incontinence. 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 57289?

CPT 57289 is a code used to describe the Pereyra procedure, which is performed to repair the vaginal wall in cases of cystocele and stress urinary incontinence. This procedure involves making an incision in the vaginal tissue over the bladder, dissecting the bladder off the tissue, and placing a suture in the retropubic fascia to suspend the urethrovesical angle. The procedure is performed through a vaginal incision.

2. Official Description

The official description of CPT code 57289 is: ‘Pereyra procedure, including anterior colporrhaphy.’

3. Procedure

1. The patient is administered anesthesia and placed in a dorsal lithotomy position.
2. The provider makes an incision in the vaginal tissue over the bladder and dissects the bladder off of this tissue.
3. Two small lower abdominal incisions are made, and a suture is placed in the retropubic fascia and looped around the neck of the bladder to join it with the urethra.
4. The suture is anchored to the abdominal wall fascia, suspending the urethrovesical angle.
5. The tissue over the bladder is plicated in the midline, and the vaginal mucosa is closed over it, completing the anterior colporrhaphy.
6. A Foley catheter is inserted, a gauze pack is placed in the vagina, and the small abdominal incisions are closed.

4. Qualifying circumstances

CPT 57289 is performed in cases where there is a cystocele (prolapse of the bladder into the vagina) and stress urinary incontinence (inability to hold urine during physical activities). The procedure is performed through a vaginal incision and is used to repair the vaginal wall. It is important to note that this procedure is specific to the Pereyra technique and includes anterior colporrhaphy.

5. When to use CPT code 57289

CPT code 57289 should be used when performing the Pereyra procedure, which involves repairing the vaginal wall in cases of cystocele and stress urinary incontinence. It should not be used for other procedures or techniques. It is important to accurately document the specific procedure performed to ensure proper coding and billing.

6. Documentation requirements

To support a claim for CPT code 57289, the following documentation is required:

• Documentation of the patient’s diagnosis of cystocele and stress urinary incontinence
• Description of the Pereyra procedure performed, including anterior colporrhaphy
• Date of the procedure
• Details of the surgical technique used
• Any additional procedures performed during the same session
• Any complications or unexpected findings
• Signature of the performing provider

7. Billing guidelines

When billing for CPT code 57289, ensure that the procedure performed is the Pereyra procedure, including anterior colporrhaphy. It is important to accurately document the procedure and any additional services provided during the same session. CPT code 57289 should not be reported with other codes unless additional procedures were performed. It is important to follow the specific guidelines provided by the payer and ensure accurate coding and billing practices.

8. Historical information

CPT code 57289, the Pereyra procedure, 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 undergoes the Pereyra procedure, including anterior colporrhaphy, to repair a cystocele and stress urinary incontinence.
2. A provider performs the Pereyra procedure, including anterior colporrhaphy, on a patient with a significant prolapse of the bladder into the vagina.
3. A patient with stress urinary incontinence undergoes the Pereyra procedure, including anterior colporrhaphy, to improve bladder support and reduce incontinence episodes.
4. A provider performs the Pereyra procedure, including anterior colporrhaphy, on a patient who has failed conservative treatments for cystocele and stress urinary incontinence.
5. A patient undergoes the Pereyra procedure, including anterior colporrhaphy, to address both a cystocele and stress urinary incontinence, improving their quality of life.
6. A provider performs the Pereyra procedure, including anterior colporrhaphy, on a patient with a history of multiple vaginal deliveries and significant bladder prolapse.
7. A patient with stress urinary incontinence undergoes the Pereyra procedure, including anterior colporrhaphy, to strengthen the support of the bladder and reduce leakage during physical activities.
8. A provider performs the Pereyra procedure, including anterior colporrhaphy, on a patient with a cystocele and stress urinary incontinence, restoring normal bladder function.
9. A patient undergoes the Pereyra procedure, including anterior colporrhaphy, to correct a cystocele and stress urinary incontinence, improving their overall pelvic floor support.