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A rectocele, also known as a proctocele, refers to the condition where there is a prolapse or herniation of the anterior wall of the rectum into the back wall of the vagina. This condition primarily affects women, although it can occur in men, albeit rarely. The repair of a rectocele is performed as a separate procedure, which means it is not typically part of a more extensive surgical operation. Various surgical approaches can be utilized for the repair, including transanal, transvaginal, perineal, abdominal, or a combination of these methods. The transvaginal approach is commonly employed, where the surgeon opens the posterior vaginal mucosa to access the rectocele. This procedure aims to restore the normal anatomy and function of the pelvic floor by addressing the herniation and reinforcing the surrounding structures. The surgical technique involves careful dissection and suturing to ensure proper healing and support for the pelvic organs.
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The repair of a rectocele is indicated for patients experiencing symptoms related to the condition. These symptoms may include:
The procedure for the repair of a rectocele involves several detailed steps to ensure effective correction of the herniation. The following outlines the procedural steps:
After the repair of a rectocele, patients can expect a recovery period that may involve some discomfort and restrictions on physical activities. Post-procedure care typically includes monitoring for any signs of complications, such as infection or excessive bleeding. Patients are often advised to avoid heavy lifting and strenuous activities for a specified period to allow for proper healing. Follow-up appointments are essential to assess the surgical site and ensure that the repair is healing as expected. Additionally, patients may receive guidance on pelvic floor exercises to strengthen the area and prevent future issues.
| Short Descr | REPAIR OF RECTOCELE | Medium Descr | REPAIR RECTOCELE SEPARATE PROCEDURE | Long Descr | Repair of rectocele (separate procedure) | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5E - Ambulatory procedures - other | MUE | 1 | CCS Clinical Classification | 129 - Repair of cystocele and rectocele, obliteration of vaginal vault |
This is a primary code that can be used with these additional add-on codes.
| 57267 | Female Edit Addon Code MPFS Status: Active Code APC N ASC N1 CPT Assistant Article Illustration for Code Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, posterior compartment), vaginal approach (List separately in addition to code for primary procedure) |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | GC | This service has been performed in part by a resident under the direction of a teaching physician | GW | Service not related to the hospice patient's terminal condition | SG | Ambulatory surgical center (asc) facility service | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| Pre-1990 | Added | Code added. |
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