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The procedure described by CPT® Code 57106 refers to a partial vaginectomy, which involves the surgical removal of a portion of the vaginal wall. This procedure is specifically characterized by the excision of the vaginal epithelium while preserving the surrounding paravaginal tissue, known as the paracolpium. During the operation, the surgeon removes the vaginal wall along with a 2 cm margin of healthy tissue that is located distal to the lesion, ensuring that the area surrounding the lesion is adequately addressed. The surgical approach begins with an incision made across the top of the vaginal vault, followed by two longitudinal full-thickness incisions—one on the anterior (ventral) side and another on the posterior (dorsal) side of the vaginal wall. These incisions extend from the top of the vaginal vault down to a point 2 cm distal to the identified lesion. The upper section of the vaginal wall, which contains the lesion, is then excised. It is important to note that if vaginal reconstruction is necessary, such as the use of skin grafts, this may be reported separately and can occur either during the same surgical session or at a later date. This procedure is distinct from other related codes, such as CPT® Code 57107, which involves a more extensive removal of the vaginal wall and surrounding tissues, and CPT® Code 57109, which includes additional lymphadenectomy procedures.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 57106 is indicated for various conditions affecting the vaginal wall. These may include:
The procedure for CPT® Code 57106 involves several critical steps to ensure the effective removal of the vaginal wall while preserving surrounding structures. The first step is to make an incision across the top of the vaginal vault, which serves as the entry point for the surgical intervention. Following this initial incision, two longitudinal full-thickness incisions are created: one along the ventral (anterior) aspect and another along the dorsal (posterior) aspect of the vaginal wall. These incisions are designed to extend from the top of the vaginal vault down to a point 2 cm distal to the lesion, allowing for adequate access to the affected area. Once the incisions are made, the surgeon excises the upper vaginal wall that contains the lesion, ensuring that a 2 cm margin of healthy tissue is also removed to minimize the risk of residual disease. This careful excision is crucial for achieving clear margins and reducing the likelihood of recurrence. It is important to note that if additional reconstruction of the vaginal wall is necessary, such as the application of skin grafts, this can be reported separately and may be performed during the same surgical session or at a later date.
After the completion of the partial vaginectomy, patients may require specific post-procedure care to ensure proper healing and recovery. This may include monitoring for any signs of infection at the surgical site, managing pain with appropriate analgesics, and following up with the healthcare provider for wound assessment. Patients are typically advised on activity restrictions to avoid strain on the surgical area during the initial recovery phase. Additionally, any necessary follow-up appointments should be scheduled to evaluate the healing process and to discuss any further treatment options if indicated, especially in cases where malignancy was present. It is essential for patients to adhere to the post-operative instructions provided by their healthcare team to promote optimal recovery outcomes.
| Short Descr | VAGNC PRTL RMVL VAG WALL | Medium Descr | VAGINECTOMY PARTIAL REMOVAL VAGINAL WALL | Long Descr | Vaginectomy, partial removal of vaginal wall; | 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 | 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. | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | 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. | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient 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). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 62 | Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate. | 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.) | 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). | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | CR | Catastrophe/disaster related | 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 | LT | Left side (used to identify procedures performed on the left side of the body) | PD | Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | SA | Nurse practitioner rendering service in collaboration with a physician | 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. |
| 2011-01-01 | Changed | Short description changed. |
| 2010-01-01 | Changed | Code description changed. |
| 1999-01-01 | Added | First appearance in code book in 1999. |
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