CPT 57135 describes the excision of a cyst or tumor in the vagin*l wall. This article will cover the description, procedure, qualifying circ*mstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.
1. What is CPT Code 57135?
CPT 57135 is used to describe the surgical removal of a cyst or tumor in the vagin*l wall. This procedure is performed by a healthcare provider and involves excising the entire semisolid material or fully removing the tumor along with supportive healthy tissues surrounding it. The excision is done through an incision made in the vagin*l mucosa, and the provider may send a sample of the cyst to the laboratory for examination. Local anesthesia is administered, and the patient is positioned in the dorsal lithotomy position during the procedure.
2. Official Description
The official description of CPT code 57135 is: ‘Excision of vagin*l cyst or tumor.’
3. Procedure
- The healthcare provider administers local anesthesia to the patient.
- The patient is positioned in the dorsal lithotomy position.
- The provider cleans the area of the cyst with plain water or dilute vinegar.
- The provider carefully examines the cyst or tumor area for excision under local anesthesia.
- An incision is made in the vagin*l mucosa over the cyst or around the tumor.
- The provider excises the whole semisolid material of the cyst or fully removes the vagin*l tumor along with supportive healthy tissues around it.
- A sample of the cyst may be sent to the laboratory for examination.
- The provider closes the incision with absorbable sutures.
- The vagin* may be packed with bleached cotton cloth.
4. Qualifying circ*mstances
CPT 57135 is used for the excision of vagin*l cysts or tumors. These cysts or tumors can be of various types, such as Gartner’s duct cyst, Bartholin’s cyst, small cysts, or benign tumors. It is important to note that this code should not be used for the drainage of a vagin*l cyst. vagin*l tumors are abnormal growths of tissue in the vagin*, and they can be primary or secondary vagin*l cancer.
5. When to use CPT code 57135
CPT code 57135 should be used when a healthcare provider performs the excision of a vagin*l cyst or tumor. It is important to ensure that the excision is done through an incision in the vagin*l mucosa and that the entire semisolid material of the cyst or the tumor, along with supportive healthy tissues, is removed. This code should not be used for the drainage of a vagin*l cyst.
6. Documentation requirements
To support a claim for CPT 57135, the healthcare provider must document the following information:
- Patient’s diagnosis indicating the presence of a vagin*l cyst or tumor
- Details of the excision procedure, including the incision made and the removal of the cyst or tumor
- Use of local anesthesia
- Any additional procedures performed, such as sending a cyst sample to the laboratory
- Details of the closure of the incision with absorbable sutures
- Use of vagin*l packing, if applicable
7. Billing guidelines
When billing for CPT 57135, ensure that the excision is performed by a healthcare provider and that the entire semisolid material of the cyst or the tumor, along with supportive healthy tissues, is removed. It is important to note that this code should not be reported for the drainage of a vagin*l cyst. There are no specific guidelines regarding reporting CPT 57135 with other codes.
8. Historical information
CPT 57135 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.
9. Examples
- A healthcare provider performs the excision of a vagin*l cyst in a patient who presents with symptoms of discomfort and swelling in the vagin*l area.
- During a routine gynecological examination, a healthcare provider identifies a vagin*l tumor and performs its excision using CPT code 57135.
- A patient with a history of vagin*l cysts undergoes the excision of a recurrent cyst using CPT code 57135.
- A healthcare provider performs the excision of a benign vagin*l tumor in a patient who has been experiencing abnormal vagin*l bleeding.
- During a surgical procedure for the removal of a vagin*l cyst, a healthcare provider discovers a small tumor and performs its excision using CPT code 57135.
- A patient with a known vagin*l tumor undergoes the excision of the tumor to alleviate symptoms and prevent further complications.
- A healthcare provider performs the excision of a Bartholin’s cyst in a patient who presents with pain and swelling in the vagin*l area.
- During a pelvic examination, a healthcare provider identifies a vagin*l tumor and performs its excision using CPT code 57135.
- A patient with a recurrent vagin*l cyst undergoes the excision of the cyst to relieve symptoms and prevent complications.
- A healthcare provider performs the excision of a small benign vagin*l tumor in a patient who has been experiencing discomfort during sexual intercourse.
