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Dilation of the vagina under anesthesia (other than local) is a medical procedure aimed at addressing various vaginal conditions and anomalies. This procedure is particularly relevant for patients with congenital issues such as incomplete transverse vaginal septa or vaginal agenesis, which refers to the absence or underdevelopment of the vaginal vault. Additionally, it serves therapeutic purposes, including the maintenance of established patency or depth of the vaginal canal to prevent stenosis, which is the narrowing of the vaginal passage. This procedure may also be indicated for patients who have experienced scarring or stenosis resulting from trauma or radiation therapy. During the procedure, the patient is placed under a form of anesthesia that is not local, ensuring that they are comfortable and pain-free. The clinician utilizes vaginal obturators or dilators that progressively increase in size, applying firm yet gentle pressure for several minutes. This technique effectively stretches and lengthens the vaginal walls, thereby enlarging the vaginal canal to facilitate further treatment or home dilation by the patient.
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The dilation of the vagina under anesthesia is indicated for several specific conditions and scenarios, including:
The procedure for vaginal dilation under anesthesia involves several key steps that ensure the effective stretching and enlargement of the vaginal canal:
Following the dilation procedure, patients may experience some discomfort or mild cramping, which is typically manageable. It is essential for the clinician to provide clear post-procedure care instructions, which may include recommendations for pain management and activity restrictions. Patients may also receive guidance on how to perform home dilation safely and effectively, if indicated. Follow-up appointments may be scheduled to monitor the healing process and ensure that the vaginal canal remains patent. Any signs of complications, such as excessive bleeding or infection, should be reported to the healthcare provider immediately.
| Short Descr | DILATION OF VAGINA | Medium Descr | DILATION VAGINA W/ANESTHESIA OTHER THAN LOCAL | Long Descr | Dilation of vagina under anesthesia (other than local) | Status Code | Active Code | Global Days | 000 - Endoscopic or Minor Procedure | 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) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | 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) | P6C - Minor procedures - other (Medicare fee schedule) | MUE | 1 | CCS Clinical Classification | 131 - Other non-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. | 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. | 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.) | GC | This service has been performed in part by a resident under the direction of a teaching physician | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | GY | Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit | KX | Requirements specified in the medical policy have been met | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2009-01-01 | Changed | Code description changed |
| Pre-1990 | Added | Code added. |
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