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Official Description

Revision (including removal) of prosthetic vaginal graft; open abdominal approach

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 57296 involves the revision or removal of a prosthetic vaginal graft through an open abdominal approach. This surgical intervention is necessary when complications arise from a previously placed graft, which may include issues such as stricture or infection. The process begins with an incision in the lower abdomen, allowing the surgeon to access the newly formed vagina and the graft material that requires attention. During the procedure, the surgeon assesses the specific complications that necessitate the revision. Depending on the findings, the surgeon may need to excise and remove portions of eroded mesh material, replace the graft material, or revise the existing graft and surrounding tissue to restore proper function. The surgical technique includes making appropriate vaginal incisions to facilitate access to the graft. Once the necessary adjustments are made, the graft material and vaginal tissue are carefully rearranged and re-approximated to create a functioning neovagina. The procedure concludes with the closure of all layers of tissue and the placement of vaginal packing to support the healing process.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure is indicated for patients experiencing complications related to a previously placed prosthetic vaginal graft. These complications may include:

  • Stricture - A narrowing of the vaginal canal that can impede normal function.
  • Infection - An infection that may compromise the integrity of the graft and surrounding tissues.

2. Procedure

The procedure consists of several critical steps to ensure the successful revision or removal of the prosthetic vaginal graft:

  • Step 1: Incision - The surgeon begins by making an incision in the lower abdomen. This incision provides access to the newly formed vagina and the graft material that requires revision or removal.
  • Step 2: Assessment - Once access is achieved, the surgeon assesses the condition of the graft and the surrounding tissues. This assessment is crucial for determining the appropriate course of action, whether it involves excising eroded mesh material, replacing the graft, or revising the existing graft.
  • Step 3: Graft Revision or Removal - Depending on the findings from the assessment, the surgeon may proceed to excise any eroded portions of the graft material. If necessary, new graft material may be introduced, or the existing graft may be revised to restore its function.
  • Step 4: Tissue Rearrangement - After addressing the graft issues, the surgeon rearranges and re-approximates the vaginal tissue to form a functioning neovagina. This step is essential for ensuring proper anatomical structure and function.
  • Step 5: Closure - The final step involves closing all layers of tissue meticulously. The surgeon ensures that the closure is secure to promote healing and minimize complications.
  • Step 6: Vaginal Packing - To support the healing process, vaginal packing is placed at the end of the procedure. This packing helps maintain the integrity of the newly formed vaginal structure during the initial recovery phase.

3. Post-Procedure

Post-procedure care involves monitoring the patient for any signs of complications, such as infection or excessive bleeding. Patients may be advised on activity restrictions and follow-up appointments to assess healing and graft function. Proper care and adherence to post-operative instructions are crucial for a successful recovery and the long-term success of the graft revision or removal.

Short Descr REVISE VAG GRAFT OPEN ABD
Medium Descr REVJ W/RMVL PROSTHETIC VAGINAL GRAFT ABDML APPR
Long Descr Revision (including removal) of prosthetic vaginal graft; open abdominal approach
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 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
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).
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.
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.)
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).
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
Date
Action
Notes
2011-01-01 Changed Short description changed.
2007-01-01 Added First appearance in code book in 2007.
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