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The procedure described by CPT® Code 57335 refers to a vaginoplasty performed specifically for individuals with an intersex state. An intersex state is characterized by the presence of both male and female anatomical features, which can complicate gender identification based solely on external genital appearance. This condition encompasses various forms, including true hermaphroditism, where an individual possesses both ovarian and testicular tissue, and pseudohermaphroditism, which can be classified into female and male types. A true hermaphrodite has both male and female reproductive organs, while a female pseudohermaphrodite is genetically female but has external genitalia that resemble male structures, such as a penis. Conversely, a male pseudohermaphrodite is genetically male but has underdeveloped external genitalia. The vaginoplasty procedure aims to construct a functional vagina, and the surgical approach may vary based on the specific anatomical characteristics present in the patient. Techniques may involve utilizing existing genital structures to form the vagina, such as inverting a penis or utilizing testicular tissue. In cases where the existing genitalia are inadequate for inversion, surgeons may employ grafts from various sources, including labial tissue, penile tissue, or scrotal skin. Additionally, alternative grafts or flaps may be harvested from areas such as the oral mucosa, buttocks, lower abdomen, or intestinal mucosa to facilitate the creation of a vagina. This procedure is essential for individuals with intersex conditions, as it can help align their physical anatomy with their gender identity and improve their quality of life.
© Copyright 2025 Coding Ahead. All rights reserved.
The vaginoplasty for intersex state, as described by CPT® Code 57335, is indicated for individuals presenting with anatomical characteristics of both sexes, which may include the following conditions:
The vaginoplasty procedure for intersex state involves several critical steps, which may vary based on the specific anatomical features of the patient. The following outlines the procedural steps:
Post-procedure care following a vaginoplasty for intersex state is essential for optimal recovery. Patients are typically advised to follow specific guidelines to promote healing and minimize complications. This may include recommendations for activity restrictions, hygiene practices, and follow-up appointments to monitor the surgical site. Patients may also receive guidance on managing any discomfort or pain associated with the recovery process. It is crucial for healthcare providers to ensure that patients understand the importance of adhering to postoperative care instructions to achieve the best possible outcomes.
| Short Descr | REPAIR VAGINA | Medium Descr | VAGINOPLASTY INTERSEX STATE | Long Descr | Vaginoplasty for intersex state | 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 | 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). | 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. | 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 | KX | Requirements specified in the medical policy have been met |
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| 2011-01-01 | Changed | Medium description changed. |
| 1992-01-01 | Added | First appearance in code book in 1992. |
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