2025 CPT code 57250
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Female Genital System Surgery Feed
Posterior colporrhaphy; repair of rectocele with or without perineorrhaphy.
Modifiers may be applicable depending on the circumstances of the procedure.Consult your local coding guidelines for specific modifier use.
Medical necessity is established by symptoms consistent with a rectocele (e.g., vaginal pressure, bowel dysfunction, pelvic discomfort), confirmed by physical examination and potentially imaging studies.The repair is medically necessary to alleviate these symptoms and improve the patient's quality of life.
The clinical responsibility lies with the surgeon who performs the procedure, including pre-operative assessment, surgical repair, and post-operative care.Anesthesiologist may also be involved in administering anesthesia.
In simple words: This surgery fixes a bulge of the rectum into the vagina (rectocele). It might also include fixing the tissues between the vagina and anus (perineum). The doctor repairs the vaginal wall and strengthens the area.
Posterior colporrhaphy involves surgical repair of a rectocele (bulging of the rectum into the vagina) with or without simultaneous perineorrhaphy (repair of the perineum). The procedure typically includes plication of the rectovaginal fascia to elevate the rectum and restore the integrity of the vaginal wall. Perineorrhaphy, if performed, strengthens the perineal muscles and tissues.The surgeon may utilize various surgical techniques depending on the extent of the rectocele and patient-specific factors. This code encompasses the repair of a rectocele with or without a posterior colporrhaphy, but if a rectocele is repaired as a separate procedure without posterior colporrhaphy, code 45560 should be used instead.
Example 1: A 60-year-old woman presents with symptoms of a rectocele, including vaginal pressure and difficulty with bowel movements.A physical examination reveals a significant rectocele. The surgeon performs a posterior colporrhaphy with perineorrhaphy to repair the rectocele and strengthen the pelvic floor.Code 57250 is reported., A 45-year-old woman undergoes a hysterectomy. During the procedure, the surgeon identifies a small rectocele and repairs it simultaneously with the hysterectomy. In this case, code 57250 is reported as part of the overall procedure., A 72-year-old woman presents with a significant rectocele and prolapse of the anterior vaginal wall. The surgeon performs a posterior colporrhaphy for the rectocele, however, the anterior vaginal wall repair is billed separately.Code 57250 is reported for the posterior colporrhaphy.
Complete medical history including symptoms, physical exam findings documenting the rectocele, operative report detailing the surgical technique used (including whether perineorrhaphy was performed), and post-operative progress notes.
** The decision to use code 57250 versus 45560 is crucial for accurate billing.Detailed documentation of the surgical procedure is essential to justify the selection of 57250.
- Revenue Code: P1G (MAJOR PROCEDURE - OTHER)
- RVU: The relative value units (RVUs) for this code vary depending on geographic location and other factors.Consult your local fee schedule for the most up-to-date information.
- Global Days: The global surgical period for this procedure is not explicitly defined in the provided data and would need to be determined based on local guidelines and payer policies.
- Payment Status: Active
- Modifier TC rule: The TC modifier is not typically applicable to this code as it represents the entire procedure.
- Fee Schedule: Historical fee schedules vary by location and payer. Consult historical payer records for specific data.
- Specialties:Gynecology, Urogynecology
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center