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The procedure described by CPT® Code 57308 involves the closure of a rectovaginal fistula using a transperineal approach, which is a surgical technique that accesses the fistula through the perineum. A rectovaginal fistula is defined as an abnormal connection between the rectum and the vagina, which can be either congenital (present at birth) or acquired later in life. Acquired fistulas may arise from various causes, including infections, traumatic injuries to the perineum during childbirth, complications from surgical procedures involving the vagina or rectum, or as a result of radiation therapy for cancer treatment. The surgical approach entails a series of meticulous steps aimed at excising the fistula and reconstructing the affected areas to restore normal anatomy and function. This procedure may also include perineal body reconstruction, which is the repair of the tissue between the vagina and rectum, and may involve levator plication, a technique used to tighten the pelvic floor muscles if necessary. The overall goal of this surgical intervention is to effectively close the fistula, promote healing, and prevent future complications, thereby improving the patient's quality of life.
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The closure of a rectovaginal fistula using CPT® Code 57308 is indicated for patients presenting with the following conditions:
The procedure for the closure of a rectovaginal fistula involves several critical steps, each designed to ensure effective repair and restoration of normal anatomy:
After the closure of the rectovaginal fistula, patients can expect a recovery period that may involve monitoring for any signs of complications, such as infection or recurrence of the fistula. Post-operative care typically includes pain management, instructions for wound care, and guidelines for activity restrictions to promote healing. Follow-up appointments are essential to assess the surgical site and ensure proper recovery. Patients may also receive education on pelvic floor exercises to strengthen the area and prevent future issues.
| Short Descr | FISTULA REPAIR TRANSPERINE | Medium Descr | CLSR RECTOVAG FSTL TPRNL PRNL BDY RCNSTJ | Long Descr | Closure of rectovaginal fistula; transperineal approach, with perineal body reconstruction, with or without levator plication | 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). | 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. | 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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| 2011-01-01 | Changed | Short description changed. |
| 1998-01-01 | Added | First appearance in code book in 1998. |
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