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The procedure described by CPT® Code 56800 refers to the plastic repair of the vaginal introitus, which is the opening of the vagina. This surgical intervention is specifically aimed at addressing vaginal outlet stenosis, a condition that can arise as a complication from an episiotomy—a surgical cut made during childbirth to facilitate delivery—or following a posterior repair, which is a surgical procedure to correct issues in the posterior vaginal wall. During the procedure, the physician makes an incision at the posterior fold of the labia minora, also known as the posterior fourchette. This incision allows access to the underlying structures. The next step involves dissecting the posterior vaginal wall away from the perineal body, which is the area between the vaginal opening and the anus. A triangular section of skin is then excised from the perineum, starting at the posterior fourchette and extending towards the anus. This excision exposes the superficial transverse perineal muscle, which is crucial for the structural integrity of the pelvic floor. To facilitate the widening of the vaginal outlet, a series of small incisions are made in this muscle. Following this, the posterior vaginal mucosa is mobilized and sutured to the perineal skin to effectively cover the surgical defect created by the excision. This meticulous approach aims to restore normal anatomy and function to the vaginal introitus, thereby alleviating the symptoms associated with vaginal outlet stenosis.
© Copyright 2025 Coding Ahead. All rights reserved.
The plastic repair of the vaginal introitus, as described by CPT® Code 56800, is indicated for the following conditions:
The procedure for the plastic repair of the vaginal introitus involves several critical steps to ensure effective treatment of vaginal outlet stenosis:
Post-procedure care following the plastic repair of the vaginal introitus typically involves monitoring for any signs of complications, such as infection or excessive bleeding. Patients may be advised to avoid sexual intercourse 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 appropriately. Additionally, patients may receive instructions on pain management and care of the surgical area to promote recovery.
| Short Descr | PLASTIC REPAIR INTROITUS | Medium Descr | PLASTIC REPAIR INTROITUS | Long Descr | Plastic repair of introitus | Status Code | Active Code | Global Days | 010 - Minor Procedure | 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) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 132 - Other OR therapeutic procedures, female organs |
| 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. | 53 | Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, 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). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician | KX | Requirements specified in the medical policy have been met | 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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| 2025-01-01 | Changed | Short Description changed. |
| Pre-1990 | Added | Code added. |
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