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The procedure described by CPT® Code 57230 refers to the plastic repair of a urethrocele, which is a condition characterized by the prolapse or bulging of the urethra into the vaginal wall. This surgical intervention is performed to restore the normal anatomical position of the urethra, which may have been compromised due to factors such as childbirth, aging, or other conditions that weaken the pelvic support structures. The procedure is conducted through a vaginal approach, allowing the physician to access the affected area directly. The use of a tenaculum on the cervix aids in stabilizing the surgical field, while a transverse incision is made to facilitate dissection and repair. The surgical technique involves careful dissection of the vaginal mucosa from the cervical fascia, ensuring that the urethra is adequately separated from surrounding tissues. The identification of the urethrovesical angle is crucial for the successful placement of plication sutures, which help to fold and secure the fascia, effectively reducing the prolapse. The procedure concludes with the closure of the vaginal mucosa and the placement of a Foley or suprapubic catheter to ensure proper urinary drainage during the initial recovery phase.
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The plastic repair of urethrocele, as described by CPT® Code 57230, is indicated for patients experiencing the following conditions:
The procedure for the plastic repair of urethrocele involves several critical steps to ensure effective repair and restoration of normal anatomy:
After the completion of the plastic repair of urethrocele, patients are typically monitored for any immediate complications. The placement of a Foley or suprapubic catheter is essential for managing urinary output and ensuring that the bladder is adequately drained during the initial recovery phase. Patients may experience some discomfort or swelling in the vaginal area, which is expected following such a surgical intervention. Follow-up appointments are necessary to assess healing and to remove the catheter as appropriate. Patients are advised on post-operative care, including activity restrictions and signs of potential complications, such as infection or excessive bleeding, that should prompt immediate medical attention.
| Short Descr | REPAIR OF URETHRAL LESION | Medium Descr | PLASTIC REPAIR URETHROCELE | Long Descr | Plastic repair of urethrocele | 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 | 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 | 129 - Repair of cystocele and rectocele, obliteration of vaginal vault |
| 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. | 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. | 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 | GC | This service has been performed in part by a resident under the direction of a teaching physician | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| Pre-1990 | Added | Code added. |
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