2025 CPT code 57285
Effective Date: N/A Surgery - Surgical Procedures on the Female Genital System Feed
Paravaginal defect repair (including repair of cystocele, if performed) using a vaginal approach.
Modifiers may be applicable. Modifier 22 (Increased Procedural Services) would be appropriate for a significantly more complex procedure than typically required, such as extensive lysis of adhesions or unusually large defect.
Medical necessity for 57285 must be supported by documentation of symptomatic pelvic organ prolapse related to the paravaginal defect. Symptoms may include pelvic pressure, urinary incontinence, or bowel dysfunction.
The physician is responsible for the complete surgical procedure, including pre-operative evaluation, patient positioning, anesthesia administration, surgical repair of the paravaginal defect and cystocele (if present), and post-operative care.
In simple words: This procedure repairs a weakened area between the vagina and bladder, often accompanied by a bladder prolapse repair (cystocele).The surgeon works through the vagina to access the area, repositioning and securing tissues for improved support.
The provider repairs a paravaginal defect by dissecting the tissues between the vagina, the bladder, and the urethra using a vaginal approach. The provider may also perform a cystocele repair as part of this procedure.The provider places the patient in the dorsal lithotomy position and administers anesthesia. An incision is made in the anterior vaginal wall to access the space of Retzius. The bladder is dissected away from the vaginal tissue, extending the dissection to expose the arcus tendineus fascia pelvis on both sides. Sutures are placed along the side of the vagina through the pubocervical fascia and brought through the obturator internus muscle. These sutures are tied to close the defect, and the fascia is then closed. If a cystocele is present, additional sutures are used to strengthen and close the anterior vaginal wall, providing better support to the bladder.
Example 1: A 45-year-old female presents with symptomatic vaginal prolapse and a cystocele. Physical examination confirms a paravaginal defect.She undergoes a paravaginal defect repair (57285) with concomitant cystocele repair., A 60-year-old female with a history of hysterectomy complains of pelvic pressure and urinary incontinence.Examination reveals a paravaginal defect.She undergoes a paravaginal defect repair (57285) without cystocele repair., A 50-year-old female with a significant paravaginal defect and recurrent cystoceles despite previous repairs elects to undergo a paravaginal defect repair (57285) with mesh augmentation (+57267 if applicable).
Documentation should include details of the pelvic exam findings, confirmation of the paravaginal defect, presence or absence of a cystocele, surgical technique employed, type of anesthesia, and any complications. If mesh is used, it should be specifically documented.
- Revenue Code: P1G - MAJOR PROCEDURE - OTHER
- Specialties:Urogynecology, Female Pelvic Medicine and Reconstructive Surgery (FPMRS), Obstetrics and Gynecology
- Place of Service:Ambulatory Surgical Center, Hospital Outpatient Department, Physician's Office