2025 CPT code 57260
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Female Genital System Surgery Feed
Combined anterior and posterior colporrhaphy, with or without cystourethroscopy.
Modifiers may be applied as clinically indicated (e.g., 51 for multiple procedures, 22 for increased procedural services, etc.).
Medical necessity for this procedure is established by symptoms of pelvic organ prolapse (POP) such as urinary incontinence, pelvic pressure, constipation, and dyspareunia. The severity of symptoms and the degree of prolapse should be documented to support the need for surgical intervention.
The surgeon performs the procedure, administering anesthesia and making the necessary incisions and sutures.Postoperative care is also part of the clinical responsibility. Cystourethroscopy may be included, as per the clinical indication.
In simple words: This surgery repairs weakened vaginal tissues to support the bladder and rectum, correcting problems like bladder or rectal tissue bulging into the vagina. The doctor may also use a scope to check the bladder and urethra.
This procedure involves the surgical repair of defects in both the anterior and posterior vaginal walls.The anterior repair addresses cystocele (prolapse of the bladder into the vagina), while the posterior repair addresses rectocele (bulging of rectal tissue into the vagina).The surgeon may also perform cystourethroscopy (examination of the bladder and urethra) to assess the integrity of these structures after the repair.The procedure typically involves plication (suturing to shorten and strengthen) of the pubocervical fascia (anteriorly) and rectovaginal fascia (posteriorly). Excess vaginal tissue may be removed.In some cases, perineorrhaphy (repair of the perineum) may also be performed.
Example 1: A 60-year-old woman presents with symptoms of urinary incontinence and a feeling of pelvic pressure.Physical examination reveals a cystocele and rectocele.A combined anterior and posterior colporrhaphy with cystourethroscopy is performed to correct these prolapses., A 55-year-old woman undergoes a hysterectomy and, during the procedure, the surgeon notes a significant cystocele.An anterior colporrhaphy is performed as part of the hysterectomy.Because of significant symptoms, a posterior colporrhaphy is also performed. Postoperatively, cystourethroscopy was performed to confirm complete bladder repair., A 48-year-old woman complains of vaginal pressure and bowel dysfunction after vaginal delivery.Pelvic exam shows a large rectocele and a small cystocele.The surgeon performs a combined anterior and posterior colporrhaphy, but cystourethroscopy is not indicated given the minimally impacted bladder.
Preoperative assessment including patient history and physical examination documenting the presence of cystocele and/or rectocele. Operative report detailing the surgical technique, including the specific repairs performed (anterior, posterior, and perineorrhaphy if applicable).Postoperative progress notes documenting patient recovery.Imaging studies (if any) used to assess the pelvic floor and confirm diagnosis.Documentation of any pre-existing conditions that may affect the surgical procedure and recovery.Consent forms.
** This code encompasses a range of surgical techniques to correct anterior and posterior vaginal wall prolapses.The specifics of the procedure performed should be accurately documented in the operative report to ensure appropriate reimbursement.
- Revenue Code: P1G (Major Procedure - Other)
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:Gynecology, Urogynecology
- Place of Service:Office, Ambulatory Surgical Center, Inpatient Hospital