How To Use CPT Code 57556

CPT 57556 describes the excision of the cervical stump through a vaginal approach, along with the repair of an enterocele. 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 57556?

CPT 57556 is used to describe the surgical procedure of removing the remaining cervical stump after a previous subtotal hysterectomy. This excision is performed through a vaginal approach, and it also includes the repair of an enterocele, which is a bulging of the small intestines and peritoneum into the vaginal canal.

2. Official Description

The official description of CPT code 57556 is: ‘Excision of cervical stump, vaginal approach; with repair of enterocele.’

3. Procedure

1. The patient is positioned in lithotomy position, with knees bent and spread apart using stirrups.
2. A speculum is inserted into the vagina, and retractors are used to hold the labia out of the way.
3. The cervical stump is injected with a local anesthetic mixed with a vasoconstrictor to minimize bleeding.
4. A circular incision is made around the stump, and it is dissected away from the vaginal tissue using scissors.
5. Clamps are placed on the cardinal ligaments and uterosacral ligaments to further detach the cervical stump.
6. If the round ligaments are attached to the stump, they are transected.
7. The cervical stump is then removed.
8. The physician proceeds to repair the enterocele overlying the vaginal mucosa.
9. The perirectal fascia of the posterior vaginal mucosa is dissected to reveal the enterocele sac.
10. The sac is cut, and the small intestine is pushed back into the abdomen and sutured closed.
11. The sac is closed with sutures, and the vaginal incision is closed as well.

4. Qualifying circumstances

CPT 57556 is performed when a patient has previously undergone a subtotal hysterectomy and also has an enterocele. The procedure is done through a vaginal approach, and it involves the excision of the cervical stump and repair of the enterocele. The patient must meet these specific circumstances to qualify for this procedure.

5. When to use CPT code 57556

CPT code 57556 should be used when a physician performs the excision of the cervical stump through a vaginal approach and also repairs an enterocele. It is important to ensure that the patient meets the qualifying circumstances for this procedure. If the procedure is not performed as described in the code, a different code should be used.

6. Documentation requirements

To support a claim for CPT 57556, the physician must document the following information:

• Patient’s medical history, including the previous subtotal hysterectomy
• Details of the procedure, including the approach used and the repair of the enterocele
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the physician performing the procedure

7. Billing guidelines

When billing for CPT 57556, ensure that the procedure meets the specific criteria outlined in the code description. It is important to accurately document the details of the procedure and any associated repairs. CPT code 57556 should not be reported with other codes unless additional procedures were performed. It is essential to follow the specific billing guidelines provided by the payer to ensure proper reimbursement.

8. Historical information

CPT 57556 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 patient who previously had a subtotal hysterectomy undergoes the excision of the cervical stump through a vaginal approach, along with the repair of an enterocele.
2. A physician performs the removal of the remaining cervical stump and repairs an enterocele in a patient who had a subtotal hysterectomy.
3. During a vaginal approach, a physician excises the cervical stump and repairs an enterocele in a patient who previously had a subtotal hysterectomy.
4. A patient with a history of subtotal hysterectomy undergoes the excision of the cervical stump and repair of an enterocele through a vaginal approach.
5. A physician performs the removal of the cervical stump and repairs an enterocele in a patient who had a previous subtotal hysterectomy, using a vaginal approach.
6. Through a vaginal approach, a physician excises the cervical stump and repairs an enterocele in a patient who previously had a subtotal hysterectomy.
7. A patient who had a subtotal hysterectomy undergoes the excision of the cervical stump and repair of an enterocele, performed through a vaginal approach.
8. A physician performs the removal of the remaining cervical stump and repairs an enterocele in a patient who had a subtotal hysterectomy, using a vaginal approach.
9. During a vaginal approach, a physician excises the cervical stump and repairs an enterocele in a patient who previously had a subtotal hysterectomy.
10. A patient with a history of subtotal hysterectomy undergoes the excision of the cervical stump and repair of an enterocele through a vaginal approach.