How To Use CPT Code 57400

CPT 57400 describes the dilation of the vagina under anesthesia (other than local). 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 57400?

CPT 57400 involves the gradual dilation of the vagina using calibrated instruments. This procedure is performed when the vaginal canal is closed due to adhesion formation or injury. The physician inserts a series of progressively larger vaginal dilators to stretch and open the vaginal walls, allowing for increased width and length of the tissue.

2. Official Description

The official description of CPT code 57400 is: ‘Dilation of vagina under anesthesia (other than local).’ There are no additional notes or modifiers associated with this code.

3. Procedure

1. The patient is positioned in the dorsal lithotomy position, and anesthesia other than local is administered.
2. The physician moistens the tip of the vaginal dilator with jelly or baby oil.
3. The physician inserts the dilators through the vaginal opening, repeatedly and slowly, in upwards and backwards directions.
4. The physician gradually increases the size of the dilators to stretch the vaginal walls and open the vaginal canal.
5. Once the desired dilation is achieved, the physician withdraws the vaginal dilators.

4. Qualifying circumstances

CPT 57400 is performed when the vaginal canal is closed due to adhesion formation or injury. It is important to note that this procedure requires the use of calibrated instruments and anesthesia other than local. The physician must assess the patient’s condition and determine the need for vaginal dilation before proceeding with the procedure.

5. When to use CPT code 57400

CPT code 57400 should be used when a physician performs the dilation of the vagina under anesthesia (other than local) to address adhesion formation or injury. 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 57400, the physician must document the following information:

• Patient’s diagnosis indicating the need for vaginal dilation
• Details of the procedure, including the use of calibrated instruments and anesthesia other than local
• Date and duration of the procedure
• Any complications or additional interventions performed
• Signature of the performing physician

7. Billing guidelines

When billing for CPT 57400, ensure that the procedure meets the specific criteria outlined in the code description. It is important to accurately report the use of anesthesia other than local and the use of calibrated instruments. Additionally, review any applicable modifiers or guidelines provided by the payer to ensure proper reimbursement.

8. Historical information

CPT 57400 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 vaginal dilation under anesthesia for a patient with vaginal adhesions resulting from previous surgery.
2. A gynecologist uses calibrated instruments to gradually dilate the vagina of a patient with vaginal stenosis caused by radiation therapy.
3. A surgeon performs vaginal dilation under anesthesia to address vaginal scarring due to trauma.
4. A physician performs vaginal dilation for a patient with vaginal agenesis, a congenital condition resulting in the absence or underdevelopment of the vagina.
5. A gynecologist performs vaginal dilation under anesthesia to address vaginal adhesions in a patient with a history of pelvic inflammatory disease.