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The CPT® Code 57111 refers to a surgical procedure known as a complete radical vaginectomy, which involves the total removal of the vaginal wall along with the adjacent paravaginal tissue. This procedure is more extensive than a standard vaginectomy, as it not only excises the vaginal wall but also includes the removal of the paracolpium, the connective tissue surrounding the vagina. The surgical approach begins with an incision made across the top of the vaginal vault, followed by two longitudinal incisions that extend full thickness along both the anterior (ventral) and posterior (dorsal) aspects of the vaginal wall. These incisions run from the top of the vaginal vault down to the introitus, or vaginal opening. Additionally, an incision is made around the introitus to facilitate the excision of the right and left halves of the vaginal wall. In the case of CPT® Code 57111, the procedure is characterized by the transection of the bladder and rectal pillars at their attachment points, allowing for the complete resection of the anterior and posterior vaginal walls, as well as the lateral paravaginal spaces. It is important to note that any subsequent vaginal reconstruction, which may involve the use of skin grafts, can be reported separately, either during the same surgical session or at a later date.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure associated with CPT® Code 57111 is indicated for various medical conditions that necessitate the complete removal of the vaginal wall and surrounding paravaginal tissue. These indications may include:
The procedure for CPT® Code 57111 involves several critical steps to ensure the complete removal of the vaginal wall and paravaginal tissue. The steps are as follows:
After the completion of the radical vaginectomy, patients may require specific post-procedure care to ensure proper healing and recovery. This may include monitoring for any signs of infection, managing pain, and providing instructions for wound care. Patients may also need to follow up with their healthcare provider for assessments of healing and to discuss any further surgical interventions, such as vaginal reconstruction with skin grafts, which may be performed at the same or a subsequent surgical session. It is essential for patients to adhere to their post-operative care plan to promote optimal recovery and minimize complications.
| Short Descr | VAGNC COMPL RMVL PARAVAG TIS | Medium Descr | VAGNC COMPL RMVL VAG WAL W/RMVL PARAVAGINAL TISS | Long Descr | Vaginectomy, complete removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy) | 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 | Inpatient Procedures, not paid under OPPS | 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 |
| 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. | 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). | 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. | 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.) | 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 |
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| 2025-01-01 | Changed | Short and Medium Descriptions changed. |
| 2011-01-01 | Changed | Short description changed. |
| 1999-01-01 | Added | First appearance in code book in 1999. |
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