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The CPT® Code 57105 refers to a procedure known as a biopsy of the vaginal mucosa that is extensive in nature and requires suture closure, including the biopsy of cystic lesions. This procedure is performed by a physician who begins by cleansing the skin and administering a local anesthetic to ensure patient comfort during the biopsy. Unlike a simpler biopsy, which is coded under CPT® 57100, the extensive biopsy represented by CPT® 57105 involves a more significant surgical intervention. In this case, the physician makes an incision in the vaginal mucosa at the site of the lesion, which may include cystic formations such as inclusion cysts, Gartner's duct cysts, or benign cystic tumors. The procedure entails the removal of a large section of abnormal tissue, which is then sent to a laboratory for pathology examination to assess the nature of the tissue. Following the biopsy, the incision is closed with sutures, indicating the complexity and extent of the procedure compared to simpler biopsy methods.
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The procedure coded under CPT® 57105 is indicated for various conditions affecting the vaginal mucosa, particularly when extensive biopsy is necessary. The following are specific indications for performing this procedure:
The procedure for CPT® 57105 involves several critical steps that ensure the effective removal of tissue for diagnostic purposes. The following outlines the procedural steps:
After the completion of the biopsy procedure coded under CPT® 57105, the patient may require specific post-procedure care to ensure proper healing and monitor for any complications. Patients are typically advised to follow up with their physician to discuss the results of the pathology examination. Additionally, they may be instructed to avoid certain activities, such as sexual intercourse or the use of tampons, for a specified period to allow the incision site to heal properly. Monitoring for signs of infection, such as increased pain, swelling, or discharge, is also essential, and patients should be informed to report any concerning symptoms to their healthcare provider promptly.
| Short Descr | BIOPSY VAGINAL MUCOSA XTNSV | Medium Descr | BIOPSY VAGINAL MUCOSA EXTENSIVE | Long Descr | Biopsy of vaginal mucosa; extensive, requiring suture (including cysts) | 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) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | 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 | 2 | CCS Clinical Classification | 130 - Other diagnostic procedures, female organs |
| 47 | Anesthesia by surgeon: regional or general anesthesia provided by the surgeon may be reported by adding modifier 47 to the basic service. (this does not include local anesthesia.) note: modifier 47 would not be used as a modifier for the anesthesia procedures. | 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). | 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). | 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. | 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.) | 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.) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | CR | Catastrophe/disaster related | GA | Waiver of liability statement issued as required by payer policy, individual case | GC | This service has been performed in part by a resident under the direction of a teaching physician | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | 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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