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The CPT® Code 57109 refers to a surgical procedure known as a partial vaginectomy, which involves the removal of a portion of the vaginal wall along with the surrounding paravaginal tissue. This procedure is classified as a radical vaginectomy and is performed in conjunction with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy). The primary goal of this procedure is to excise the affected vaginal tissue while also addressing potential lymphatic spread of malignancy by removing lymph nodes in the pelvic and para-aortic regions. The procedure is complex and may require a collaborative effort from two surgeons due to the extensive nature of the surgery. The surgical approach typically involves a midline abdominal incision to facilitate access to the pelvic area, allowing for thorough exploration and assessment for any metastatic disease. The excision of the vaginal wall is performed with careful attention to margins, ensuring that healthy tissue is preserved where possible. This procedure is indicated in cases where there is a need to remove cancerous or diseased tissue from the vaginal area, and it may be accompanied by additional reconstructive procedures if necessary.
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The procedure described by CPT® Code 57109 is indicated for patients presenting with specific conditions that necessitate the removal of part of the vaginal wall and associated paravaginal tissue. The following are the explicitly provided indications for this procedure:
The procedure for CPT® Code 57109 involves several critical steps that ensure the effective removal of the affected tissue and lymph nodes. The following procedural steps are outlined:
Post-procedure care following a CPT® Code 57109 surgery involves monitoring for complications and ensuring proper recovery. Patients may require pain management and close observation for signs of infection or bleeding. Follow-up appointments are essential to assess healing and to review pathology results from the lymph node sampling. Depending on the findings, additional treatments such as radiation or chemotherapy may be considered. Patients may also need support for any reconstructive procedures that could be performed at the same or a subsequent surgical session to restore vaginal function and appearance.
| Short Descr | VAGNC BI TOTAL PEL LYMPHADEC | Medium Descr | VAGNC PRTL RMVL VAG WALL W/BI TOT PEL LYMPHADEC | Long Descr | Vaginectomy, partial removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy) with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy) | 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) | 2 - 150% payment adjustment 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). | 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. | 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 | GC | This service has been performed in part by a resident under the direction of a teaching physician |
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| 2025-01-01 | Changed | Short and Medium Descriptions changed. |
| 1999-01-01 | Added | First appearance in code book in 1999. |
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