How To Use CPT Code 57311

CPT 57311 describes the closure of a urethrovaginal fistula using a bulbocavernosus transplant. 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 57311?

CPT 57311 can be used to describe the closure of a urethrovaginal fistula by utilizing a bulbocavernosus transplant. This code is used when a physician repairs an abnormal opening between the urethra and the vagina by creating flaps using the bulbocavernosus muscle.

2. Official Description

The official description of CPT code 57311 is: ‘Closure of urethrovaginal fistula; with bulbocavernosus transplant.’

3. Procedure

1. The patient is positioned in the dorsal lithotomy position and administered anesthesia.
2. The physician identifies the urethrovaginal fistula and makes an incision in the vaginal mucosa.
3. Fascial flaps are prepared on each side of the fistula.
4. The physician closes the urethral mucosa with absorbable sutures.
5. The prepared flaps on the right and left side are closed with synthetic absorbable sutures.
6. Fatty tissue is repaired if necessary.
7. A strip of bulbocavernosus muscle is transplanted over the excised urethrovaginal fistula.
8. A catheter is placed for drainage and healing of the urethra.

4. Qualifying circumstances

CPT 57311 is performed when there is an abnormal opening between the urethra and the vagina, known as a urethrovaginal fistula. The procedure involves the use of the bulbocavernosus muscle to create flaps that cover the repair. This code is used for patients who require closure of the fistula using a bulbocavernosus transplant.

5. When to use CPT code 57311

CPT code 57311 should be used when a physician performs a closure of a urethrovaginal fistula using a bulbocavernosus transplant. It is important to accurately document the procedure and ensure that the patient meets the qualifying circumstances for this code.

6. Documentation requirements

To support a claim for CPT 57311, the physician must document the following information:

• Patient’s diagnosis of a urethrovaginal fistula
• Description of the closure procedure performed
• Details of the bulbocavernosus transplant
• Date of the procedure
• Any additional procedures or repairs performed
• Signature of the performing physician

7. Billing guidelines

When billing for CPT 57311, ensure that the closure of the urethrovaginal fistula was performed using a bulbocavernosus transplant. Follow the appropriate coding guidelines and ensure accurate documentation to support the claim. It is important to review any specific billing requirements from insurance providers or payers.

8. Historical information

CPT 57311 was added to the Current Procedural Terminology system on January 1, 1990. In 2017, it was added to the Inpatient Only (IPO) list for Medicare.

9. Examples

1. A physician performs a closure of a urethrovaginal fistula using a bulbocavernosus transplant for a patient who developed the fistula after childbirth.
2. A surgeon repairs a urethrovaginal fistula using a bulbocavernosus transplant for a patient who experienced complications after a previous surgery.
3. A urologist performs a closure of a urethrovaginal fistula using a bulbocavernosus transplant for a patient with a history of pelvic radiation therapy.
4. A gynecologist repairs a urethrovaginal fistula using a bulbocavernosus transplant for a patient who developed the fistula after a traumatic injury.
5. An obstetrician performs a closure of a urethrovaginal fistula using a bulbocavernosus transplant for a patient with a congenital abnormality.
6. A reconstructive surgeon repairs a urethrovaginal fistula using a bulbocavernosus transplant for a patient who experienced complications after a previous surgery.
7. A urogynecologist performs a closure of a urethrovaginal fistula using a bulbocavernosus transplant for a patient with a history of chronic urinary tract infections.
8. A urologist repairs a urethrovaginal fistula using a bulbocavernosus transplant for a patient who developed the fistula after a bladder stone removal procedure.
9. A gynecologic oncologist performs a closure of a urethrovaginal fistula using a bulbocavernosus transplant for a patient who developed the fistula after undergoing chemotherapy.
10. A reconstructive surgeon repairs a urethrovaginal fistula using a bulbocavernosus transplant for a patient who experienced complications after a previous surgery.