How To Use CPT Code 57305

CPT 57305 describes the closure of a rectovaginal fistula through an abdominal incision. 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 57305?

CPT 57305 can be used to describe the closure of a rectovaginal fistula through an abdominal incision. This code is used when the provider excises the fistula and closes the defect created by its removal using staples or sutures.

2. Official Description

The official description of CPT code 57305 is: ‘Closure of rectovaginal fistula; abdominal approach.’

3. Procedure

1. The provider places the patient in a supine position and administers anesthesia.
2. A skin incision is made in the lower abdomen and carried down until the peritoneal cavity is entered.
3. The provider explores the abdominal cavity and packs the bowel away from the operative site.
4. The sigmoid colon is released from the surrounding tissue.
5. The provider enters the rectovaginal fascia and dissects the vagina from the rectum.
6. The fistula is identified and excised.
7. The defect created by removing the fistula is closed using staples or sutures.
8. The vaginal incision is closed and a drain is inserted, secured either to drain into the vaginal canal or outside the body through the abdominal wall.
9. The bowel is put back into the pelvis and the abdominal incision is closed with sutures.

4. Qualifying circumstances

Patients eligible to receive CPT 57305 services are those with a rectovaginal fistula, which is an abnormal passage between the rectum and the vagina. This condition is usually caused by obstetric injuries, incomplete healing of an episiotomy, rectocele repair, radiation therapy, or uterine cancer. The procedure is performed through an abdominal incision, and the patient must be placed in a supine position under anesthesia.

5. When to use CPT code 57305

CPT code 57305 should be used when the provider performs the closure of a rectovaginal fistula through an abdominal incision. It is important to ensure that the procedure meets the specific criteria outlined in the code description. If the closure is performed through a different approach or for a different type of fistula, a different CPT code should be used.

6. Documentation requirements

To support a claim for CPT 57305, the provider must document the following information:

• Patient’s diagnosis of a rectovaginal fistula
• Description of the procedure performed, including the approach (abdominal) and any additional details
• Date of the procedure
• Start and end time of the procedure
• Any complications or unexpected findings
• Details of the closure technique used (staples or sutures)
• Any additional procedures performed during the same operative session
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 57305, ensure that the closure of a rectovaginal fistula is performed through an abdominal incision. Use the appropriate CPT code based on the specific approach and procedure performed. It is important to follow the specific guidelines and documentation requirements outlined in the code description. Report any additional procedures performed during the same operative session using the appropriate additional CPT codes.

8. Historical information

CPT 57305 was added to the Current Procedural Terminology system on January 1, 1990. It was later added to the Inpatient Only (IPO) list for Medicare in 2017.

9. Examples

1. A provider performing the closure of a rectovaginal fistula through an abdominal incision for a patient with a history of obstetric injury.
2. A surgeon excising a rectovaginal fistula and closing the defect using sutures for a patient who underwent rectocele repair.
3. A gynecologist performing the closure of a rectovaginal fistula through an abdominal incision for a patient who developed the fistula after radiation therapy.
4. A colorectal surgeon excising a rectovaginal fistula and closing the defect using staples for a patient with uterine cancer.
5. A urogynecologist performing the closure of a rectovaginal fistula through an abdominal incision for a patient with incomplete healing of an episiotomy.
6. A provider performing the closure of a rectovaginal fistula through an abdominal incision for a patient with a history of multiple obstetric injuries.
7. A surgeon excising a rectovaginal fistula and closing the defect using sutures for a patient who developed the fistula after rectocele repair.
8. A gynecologist performing the closure of a rectovaginal fistula through an abdominal incision for a patient who developed the fistula after radiation therapy.
9. A colorectal surgeon excising a rectovaginal fistula and closing the defect using staples for a patient with uterine cancer.
10. A urogynecologist performing the closure of a rectovaginal fistula through an abdominal incision for a patient with incomplete healing of an episiotomy.