2025 CPT code 57265
(Active) Effective Date: N/A Revision Date: N/A Surgical Procedures on the Female Genital System - Repair Procedures on the Vagina Surgery Feed
Combined anterior and posterior colporrhaphy with enterocele repair, including cystourethroscopy when performed.
Modifiers may be applied as appropriate to reflect circumstances of the procedure, such as multiple procedures (modifier 51), reduced services (modifier 52), or anesthesia services (appropriate anesthesia modifiers).
Medical necessity is established by the presence of symptomatic pelvic organ prolapse affecting the patient's quality of life. Documentation should support the severity of the prolapse, its impact on the patient's daily activities, and the need for surgical intervention.
The surgeon performs the procedure under anesthesia.This involves making incisions in the vaginal walls, repairing the weakened tissues, and potentially performing cystourethroscopy.
In simple words: This surgery repairs weakened vaginal walls that support the bladder, rectum, and intestines. The doctor uses stitches to strengthen these areas, correcting prolapses (bulges) of these organs into the vagina.Sometimes, a scope is used to examine the bladder and urethra.
This procedure involves the surgical repair of defects in the anterior and posterior vaginal walls, addressing conditions such as cystocele (bladder prolapse), rectocele (rectal prolapse), and enterocele (small intestine prolapse).The surgeon makes incisions in the vaginal walls, exposes the damaged fascia, and uses sutures to plicate and reinforce the weakened tissues, supporting the bladder, urethra, rectum, and small bowel.Cystourethroscopy (examination of the bladder and urethra with a lighted instrument) may be performed to assess the integrity of these structures.Enterocele repair involves the excision or closure of the prolapsed sac of peritoneum and small bowel. The procedure may also include perineorrhaphy (repair of the perineum).
Example 1: A 60-year-old woman presents with symptoms of urinary incontinence, pelvic pressure, and a feeling of fullness in her vagina.Physical exam reveals a cystocele and rectocele.57265 is used to repair both prolapses., A 55-year-old woman undergoes a hysterectomy and during the procedure, an enterocele is discovered. 57265 is performed concurrently to repair the enterocele., A 48-year-old woman with a history of vaginal childbirth experiences symptoms of pelvic organ prolapse.An anterior and posterior colporrhaphy with enterocele repair is performed (57265) along with a perineorrhaphy.
Preoperative evaluation including patient history, physical examination documenting the prolapse, and any associated symptoms. Operative report detailing the surgical technique, including specific repairs performed (anterior colporrhaphy, posterior colporrhaphy, enterocele repair), and the use of cystourethroscopy. Postoperative progress notes.
** This CPT code covers a complex surgical procedure involving multiple repairs. Accurate coding requires thorough documentation of all aspects of the surgery performed.
- Revenue Code: P1G (Major Procedure - Other)
- Payment Status: Active
- Specialties:Obstetrics and Gynecology, Urogynecology
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center, Office