How To Use CPT Code 57310

CPT 57310 describes the procedure for the closure of a urethrovaginal fistula using a vaginal approach. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 57310?

CPT 57310 can be used to describe the closure of a urethrovaginal fistula through a vaginal approach. This code is used when a physician performs a surgical procedure to repair an abnormal opening between the urethra and the vagina.

2. Official Description

The official description of CPT code 57310 is: ‘Closure of urethrovaginal fistula; vaginal approach.’

3. Procedure

1. The patient is positioned in the dorsal lithotomy position, with knees bent and spread apart using stirrups.
2. The physician administers anesthesia to the patient.
3. The physician identifies the urethrovaginal fistula.
4. The vaginal mucosa is cut to access the fistula.
5. The physician excises the fistula tract and sutures the area closed.
6. A pad of fatty tissue is sutured between the urethra and vaginal wall to plump up the hole left after removing the fistula.
7. A catheter is left in place for drainage to aid in the healing of the urethra.

4. Qualifying circumstances

CPT 57310 is performed when there is an abnormal opening between the urethra and the vagina, known as a urethrovaginal fistula. This procedure is done through a vaginal approach and requires the expertise of a physician.

5. When to use CPT code 57310

CPT code 57310 should be used when a physician performs the closure of a urethrovaginal fistula using a vaginal approach. It is important to ensure that the procedure meets the specific criteria outlined in the code description.

6. Documentation requirements

To support a claim for CPT 57310, the physician must document the following information:

• Patient’s diagnosis of a urethrovaginal fistula
• Description of the procedure performed, including the approach used
• Date of the procedure
• Any additional details or complications encountered during the procedure
• Signature of the performing physician

7. Billing guidelines

When billing for CPT 57310, ensure that the procedure meets the specific criteria outlined in the code description. It is important to follow the appropriate coding guidelines and modifiers, if applicable. Report any additional services or procedures performed during the same encounter separately.

8. Historical information

CPT 57310 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 physician performs the closure of a urethrovaginal fistula using a vaginal approach.
2. A patient undergoes surgery to repair an abnormal opening between the urethra and the vagina.
3. A physician excises a fistula tract and sutures the area closed through a vaginal approach.
4. A urethrovaginal fistula is repaired using a pad of fatty tissue to plump up the hole left after removing the fistula.
5. A catheter is left in place for drainage following the closure of a urethrovaginal fistula.
6. A physician performs a surgical procedure to close an abnormal opening between the urethra and the vagina.
7. A patient undergoes a vaginal approach procedure to repair a urethrovaginal fistula.
8. A physician sutures the area closed after excising a fistula tract through a vaginal approach.
9. A urethrovaginal fistula is repaired using a pad of fatty tissue to aid in the healing process.
10. A catheter is left in place for drainage following the closure of a urethrovaginal fistula using a vaginal approach.