Wiki Help! Colpocleisis, Levator plication w/ Perineorrhaphy vs ant/post colporrhaphy 57260

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Need help, MD is stating procedure performed is a Colpocleisis (Complete vaginectomy) and Levator plication with perineorrhaphy. Auditor is saying this was a combined anteroposterior colporrhaphy. What is this and what CPTs to use?

FINDINGS:
Massive complete vaginal vault prolapse of 9cm of vaginal length which was primarily enterocele and cystocele.

On cystoscopy, bilateral effluxing ureteral orifices were visualized and no foreign bodies, lesions or stones seen on full bladder survey at the conclusion of the case.

PROCEDURE DESCRIPTION:
After patient was counseled and consent was reviewed, she was brought into the operating room. Once adequate anesthesia was obtained, the patient was positioned in dorsal high lithotomy position using Allen stirrups and arms were padded and out to the side in a neurologically neutral position. The sequential compression devices were in place on the legs. She was prepped and draped in the normal sterile fashion. The foley was placed to gravity. Time out was performed.

Attention was then drawn to the vagina where two allis clamps were placed to define the vaginal apex. 0.25% marcaine with epinephrine was then injected under the entire vaginal epithelium, creating a hydrodissection. The vaginal mucosa quadrants were marked with the Bovie. A vertical incision was made with a scalpel in the anterior vaginal wall mucosa. Using Metzenbaum scissors and allis clamps for retraction, the underlying fascia of the anterior and posterior vaginal walls and enterocele were dissected off full-thickness vaginal epithelium. Excess vaginal epithelium was trimmed. Using 0-Vicryl the vagina was reduced using a series of interrupted imbricating sutures. Once the enterocele, rectocele and cystocele were completely imbricated and meeting the perineum equally, a levator plication and tight perineorrhaphy was performed using interrupted 0-Vicryl sutures to narrow the vaginal introitus and build up the perineal body. This was done with a gloved finger in the rectum to ensure no rectal injury given its proximity. The vaginal epithelium was then closed using interrupted 2-0 Vicryl, with excellent hemostasis noted.
 
Your auditor is right cystocele is the anterior, rectocele is posterior enterocele was also done
57265 combined anteroposterior colporrhaphy, includes cystourethroscopy, when performed; with ENTEROCELE repair
The perineorrhaphy is included in this procedure.


Pelvic defect repair techniques
CPT Assistant, June 2002 Pages: 5,6 Category: Coding Communication

How to Code
The CPT book has several codes that describe various pelvic defect repair techniques. The proximity of multiple structures to the vaginal wall frequently results in repair(s) not only to the vaginal structure, but to the anatomic structure(s) themselves, which are intimately involved in the vaginal wall defect. Additional procedures may be required in addition to the vaginal defect repair (eg, hysterectomy, salpingo- oophorectomy). The specific procedures are reported separately. The CPT code descriptors reflect the distinctly different surgical repair approaches (eg, posterior, anterior, anteroposterior, abdominal).

57240 Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele
CPT code 57240 is reported for the treatment of anterior vaginal wall prolapse, cystocele, urethrocele, or combined cystourethrocele. The surgery, performed by vaginal approach, reduces the cystocele/urethrocele/ cystourethrocele with sutures placed in the vesicovaginal tissue. Weakened, thin, or redundant vaginal wall tissue may be excised and the resulting defect closed, possibly with a layered closure. The optimal position of the urethra is restored through reinforcement of the pubourethral fascia support and suspension of the urethra into a retro-pubic position, with further support of the bladder. As the collapse of the supportive tissues is also responsible for vaginal wall prolapse, normal vaginal depth and axis is restored.

57250 Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy
Code 57250 is intended to report rectocele repair by colporrhaphy. The approach is a posterior midline incision of the vaginal mucosa and may include the perineum. The diverging fibers of the rectovaginal fascia are repaired and brought to midline. The levator ani muscles are reinforced over the anterior rectal wall in order to strengthen the posterior paravaginal tissue until the defect is repaired. Repair of the vagina and the fibrous tissue separating the vagina and the rectum will also be performed with excision of excess posterior vaginal wall. A perineorrhaphy may also be performed, which includes midline approximation of the levator ani and perineal muscles and the puborectalis fibers.

57260 Combined anteroposterior colporrhaphy
Code 57260 is reported for combined repair of a cystocele and rectocele. The technique is that which is described above for CPT codes 57240 and 57250. When both procedures are performed at the same operative session, only code 57260 should be reported.

If a vaginal hysterectomy with removal of tubes and ovaries (CPT code 58262) is performed at the same session as an anteroposterior colporrhaphy, it would be appropriate to report both procedures performed at this surgical session. Modifier '-51' should be appended to the secondary procedure to denote the performance of multiple procedures at the same session by the same surgeon.

57265 Combined anteroposterior colporraphy; with enterocele repair
Code 57265 is intended to report the repair of multiple hernia defects. A vaginal posterior midline incision approach is performed, followed by a reduction, repair, and reinforcement of the paravaginal fascia of the perineum and posterior wall, including dissection and repair of weakened tissue between the bladder, urethra, vagina and rectum. Vaginal repair of the enterocele is also performed by excising the enterocele sac and reinforcing the support of the repaired peritoneal tissue.

57268 Repair of enterocele, vaginal approach (separate procedure)
Code 57268 is intended to be reported for repair of enterocele with excision of the enterocele sac and reinforcement to support the repaired peritoneal tissue. This procedure involves suspension of the posterior fornix of the vagina. Performance of a McCall's culdoplasty, in which the posterior fornix is suspended across the rectouterine pouch to repair tissue displacement caused by the enterocele formation is included within this procedure, and would not be separately reported.

57270 Repair of enterocele, abdominal approach (separate procedure)
Code 57270 is intended to be reported for repair of enterocele through an abdominal approach with excision of the enterocele sac and reinforcement of support for the repaired peritoneal tissue. Approximation and reinforcement of weakened rectovaginal fascia is included in this procedure. This procedure is sometimes referred to as a Halban's or Moschcowitz procedure.
CPT® Assistant copyright 1990-2022 American Medical Association. All rights reserved.

Here is a description from the coder desk reference of Colpoclesis:
57120
The physician grasps the deepest portion of the vaginal vault and everts the vagina.
Two large flaps of vaginal wall are removed from opposite sides of the prolapsed vagina.
The vaginal walls are sutured to one another and this structure is inverted back inside the body.
The former vaginal opening is closed with sutures obliterating the vagina and preventing uterine prolapse.
 
Need help, MD is stating procedure performed is a Colpocleisis (Complete vaginectomy) and Levator plication with perineorrhaphy. Auditor is saying this was a combined anteroposterior colporrhaphy. What is this and what CPTs to use?

FINDINGS:
Massive complete vaginal vault prolapse of 9cm of vaginal length which was primarily enterocele and cystocele.

On cystoscopy, bilateral effluxing ureteral orifices were visualized and no foreign bodies, lesions or stones seen on full bladder survey at the conclusion of the case.

PROCEDURE DESCRIPTION:
After patient was counseled and consent was reviewed, she was brought into the operating room. Once adequate anesthesia was obtained, the patient was positioned in dorsal high lithotomy position using Allen stirrups and arms were padded and out to the side in a neurologically neutral position. The sequential compression devices were in place on the legs. She was prepped and draped in the normal sterile fashion. The foley was placed to gravity. Time out was performed.

Attention was then drawn to the vagina where two allis clamps were placed to define the vaginal apex. 0.25% marcaine with epinephrine was then injected under the entire vaginal epithelium, creating a hydrodissection. The vaginal mucosa quadrants were marked with the Bovie. A vertical incision was made with a scalpel in the anterior vaginal wall mucosa. Using Metzenbaum scissors and allis clamps for retraction, the underlying fascia of the anterior and posterior vaginal walls and enterocele were dissected off full-thickness vaginal epithelium. Excess vaginal epithelium was trimmed. Using 0-Vicryl the vagina was reduced using a series of interrupted imbricating sutures. Once the enterocele, rectocele and cystocele were completely imbricated and meeting the perineum equally, a levator plication and tight perineorrhaphy was performed using interrupted 0-Vicryl sutures to narrow the vaginal introitus and build up the perineal body. This was done with a gloved finger in the rectum to ensure no rectal injury given its proximity. The vaginal epithelium was then closed using interrupted 2-0 Vicryl, with excellent hemostasis noted.

Need help, MD is stating procedure performed is a Colpocleisis (Complete vaginectomy) and Levator plication with perineorrhaphy. Auditor is saying this was a combined anteroposterior colporrhaphy. What is this and what CPTs to use?

FINDINGS:
Massive complete vaginal vault prolapse of 9cm of vaginal length which was primarily enterocele and cystocele.

On cystoscopy, bilateral effluxing ureteral orifices were visualized and no foreign bodies, lesions or stones seen on full bladder survey at the conclusion of the case.

PROCEDURE DESCRIPTION:
After patient was counseled and consent was reviewed, she was brought into the operating room. Once adequate anesthesia was obtained, the patient was positioned in dorsal high lithotomy position using Allen stirrups and arms were padded and out to the side in a neurologically neutral position. The sequential compression devices were in place on the legs. She was prepped and draped in the normal sterile fashion. The foley was placed to gravity. Time out was performed.

Attention was then drawn to the vagina where two allis clamps were placed to define the vaginal apex. 0.25% marcaine with epinephrine was then injected under the entire vaginal epithelium, creating a hydrodissection. The vaginal mucosa quadrants were marked with the Bovie. A vertical incision was made with a scalpel in the anterior vaginal wall mucosa. Using Metzenbaum scissors and allis clamps for retraction, the underlying fascia of the anterior and posterior vaginal walls and enterocele were dissected off full-thickness vaginal epithelium. Excess vaginal epithelium was trimmed. Using 0-Vicryl the vagina was reduced using a series of interrupted imbricating sutures. Once the enterocele, rectocele and cystocele were completely imbricated and meeting the perineum equally, a levator plication and tight perineorrhaphy was performed using interrupted 0-Vicryl sutures to narrow the vaginal introitus and build up the perineal body. This was done with a gloved finger in the rectum to ensure no rectal injury given its proximity. The vaginal epithelium was then closed using interrupted 2-0 Vicryl, with excellent hemostasis noted.
The operative note above is consistent with a colpocliesis/colpectomy. The surgeon fully removed all vagina rather than doing flaps described with the traditional LeFort technique. He then plicated the prolapse with implicating sutures most likely in a purse string fashion. Finally, he performed a levator plasty in the midline and then closed the residual vagina resulting in a blind pouch and colpocliesis/colpectomy. The operative note is not as clear as is should be which is probably why the auditor said otherwise. I would ask a surgeon who performs this procedure to review/rebut the finding.
 
The operative note above is consistent with a colpocliesis/colpectomy. The surgeon fully removed all vagina rather than doing flaps described with the traditional LeFort technique. He then plicated the prolapse with implicating sutures most likely in a purse string fashion. Finally, he performed a levator plasty in the midline and then closed the residual vagina resulting in a blind pouch and colpocliesis/colpectomy. The operative note is not as clear as is should be which is probably why the auditor said otherwise. I would ask a surgeon who performs this procedure to review/rebut the finding.
Thank you Melanie!! Following up on this... In speaking with the MD, she is essentially doing a vaginectomy, as she states she is doing a "full thickness removal of the vaginal mucosa from hymen to apex". According to my research, it should still be coded as a colpocleisis CPT 57120 as the code description for 57120 colpocleisis lists (LeFort) in parenthesis which means it is an example of the type and not an all-inclusive list. This full-thickness / complete vaginectomy is being used as an alternative to colpocleisis. Though it would appear that CPT 57110 'Vaginectomy, complete removal of vaginal wall' would be the code to use, it is not, as this CPT (57110) can only be billed as an in-patient procedure and looks like it is to be used as a treatment for vaginal cancer. Am I correct in this thought process to still use colpocleisis 57120 for this procedure? Would the perineorrhaphy and levator plication (listed in the op note 'procedures performed') be included in 57120? Or are they separately billable? If so, what code(s)? Of note, MD is also stating that a levator plication is code 57250 posterior colporrhaphy and should be coded out with these. I disagree as I do not believe they are the same thing and there is not a rectocele dx to support a 57250.
 
Hi Krista, I don't have much time at the moment but here is some information from AUGS, which may be helpful.

https://www.augs.org/assets/1/6/2019_Obliterative_Surgery_Coding_Fact_Sheet.pdf

What is the best code to use total vaginectomy, colpocleisis and cystoscopy for a complete vaginal vault prolapse?​

Per the AUGS Coding Committee, there is no single code answer for this question. The key to accurate coding is to code what was performed. The documentation of the procedure should support the submitted code and is the physician’s protection in case of audit. For colpocleisis, the code for the basic procedure is 57120. Any additional required procedures are coded with modifiers and are subject to bundling constraints. 57106 and 57110 are the codes for removal of the vaginal epithelium partially and complete. 57106 is the code for partial removal of the vaginal wall and is typically utilized with apical vaginal tissue removal. 57110 is appropriate for total removal of all vaginal epithelium. The operative report should descriptively support the identification method of all of the tissue with its removal. 52000 may be reported with 57110 when appropriate with a modifier.
 
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