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The procedure described by CPT® Code 57000, known as colpotomy with exploration, involves a surgical intervention where the posterior cervical lip is grasped using a tenaculum. This technique elevates the cervix, allowing for better visibility and access to the posterior vaginal wall. A stab incision is made in the posterior vaginal wall, which may be widened as necessary to facilitate exploration. The primary objective of this procedure is to explore the posterior cul-de-sac, which is the area located behind the uterus, for any signs of infection, disease, or other abnormalities that may be present. This exploration is critical for diagnosing conditions that may not be visible through non-invasive methods. It is important to note that this procedure is distinct from CPT® Code 57010, which involves the drainage of an abscess in the posterior cul-de-sac. In the case of an abscess, additional steps are taken to break up loculi within the abscess cavity, drain the fluid, and manage the site to ensure proper healing and recovery.
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The colpotomy with exploration procedure is indicated for various clinical scenarios where there is a need to investigate the posterior cul-de-sac for potential underlying issues. The following conditions may warrant this procedure:
The colpotomy with exploration procedure involves several key steps that are performed to ensure thorough examination and assessment of the posterior cul-de-sac. The following procedural steps are outlined:
After the colpotomy with exploration, the patient may require specific post-procedure care to ensure proper healing and recovery. It is essential to monitor the patient for any signs of complications, such as excessive bleeding or infection. The physician may provide instructions regarding activity restrictions, pain management, and signs to watch for that may indicate complications. Follow-up appointments may be scheduled to assess the healing process and discuss any findings from the exploration. If any samples were taken during the procedure, results from laboratory cultures may also be reviewed during follow-up visits.
| Short Descr | COLPOTOMY W/EXPLORATION | Medium Descr | COLPOTOMY W/EXPLORATION | Long Descr | Colpotomy; with exploration | Status Code | Active Code | Global Days | 010 - 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) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 130 - Other diagnostic 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). | 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.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure 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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| 2025-01-01 | Changed | Short Description changed. |
| Pre-1990 | Added | Code added. |
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