How To Use CPT Code 57308

CPT 57308 describes the closure of a rectovaginal fistula using a transperineal approach, with or without levator plication and perineal body reconstruction. 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 57308?

CPT 57308 is used to describe the surgical procedure performed to close a rectovaginal fistula. This procedure involves making an incision through the perineum and repairing the perineal body. The levator muscle may also be shortened if necessary. The purpose of this procedure is to restore the normal anatomy and function of the rectovaginal area.

2. Official Description

The official description of CPT code 57308 is: ‘Closure of rectovaginal fistula; transperineal approach, with perineal body reconstruction, with or without levator plication.’

3. Procedure

1. The patient is positioned in a dorsal lithotomy position and administered anesthesia.
2. The physician makes an upside-down U incision in the perineum and exposes the external anal sphincter.
3. A probe is inserted into the fistula to locate the exact tract.
4. The physician separates the fistula tract from the anal sphincter and removes any vaginal and rectal mucosa that are part of the fistula.
5. The tissue under the anal sphincter is repaired with sutures and covered with rectovaginal fascia.
6. The original perineal incision is closed using sutures.
7. If there was perineal laxity before the surgery, the levator ani muscle may be shortened by making folds or tucks on its walls and incorporating it into the surgical closure.

4. Qualifying circumstances

CPT 57308 is performed on patients with a rectovaginal fistula, which is an abnormal passage between the rectum and the vagina. This condition can be caused by various factors such as obstetric injuries, incomplete healing of an episiotomy, rectocele repair, radiation therapy, or uterine cancer. The procedure is performed using a transperineal approach, with or without levator plication and perineal body reconstruction.

5. When to use CPT code 57308

CPT code 57308 should be used when a rectovaginal fistula closure is performed using a transperineal approach, with or without levator plication and perineal body reconstruction. It is important to accurately document the details of the procedure to support the use of this code.

6. Documentation requirements

To support a claim for CPT 57308, the following documentation is required:

• Patient’s diagnosis of rectovaginal fistula
• Description of the procedure performed, including the approach used (transperineal), and whether levator plication and perineal body reconstruction were performed
• Date of the procedure
• Details of the surgical technique used
• Any additional procedures performed during the same operative session
• Signature of the performing physician

7. Billing guidelines

When billing for CPT 57308, ensure that the procedure meets the criteria described in the official description. It is important to accurately document the details of the procedure to support the use of this code. CPT code 57308 should not be reported with other codes unless additional procedures were performed during the same operative session.

8. Historical information

CPT code 57308 was added to the Current Procedural Terminology system on January 1, 1998. In 2017, it was added to the Inpatient Only (IPO) list for Medicare.

9. Examples

1. A patient undergoes a transperineal closure of a rectovaginal fistula with perineal body reconstruction and levator plication.
2. A physician performs a transperineal closure of a rectovaginal fistula with perineal body reconstruction without levator plication.
3. A patient with a rectovaginal fistula undergoes a transperineal closure with perineal body reconstruction and levator plication, as well as repair of the rectal mucosa.
4. A surgeon performs a transperineal closure of a rectovaginal fistula with perineal body reconstruction and levator plication, along with repair of the vaginal mucosa.
5. A patient undergoes a transperineal closure of a rectovaginal fistula with perineal body reconstruction and levator plication, as well as repair of the rectal and vaginal mucosa.