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The procedure described by CPT® Code 57023 involves the surgical intervention known as incision and drainage of a vaginal hematoma that is classified as non-obstetrical. A vaginal hematoma is a localized collection of blood that occurs within the vaginal tissue, which can arise due to various reasons, including trauma or spontaneous bleeding. In this procedure, the physician first identifies the hematoma, assessing its location and size to determine the best approach for intervention. The next step involves making an incision in the skin that covers the hematoma, allowing for the drainage of the accumulated blood and the evacuation of any clots present. Following the drainage, the physician evaluates the site for any signs of active bleeding, and if necessary, ligates any bleeding vessels to prevent further blood loss. Depending on the clinical situation, the incision may either be closed or left open to facilitate healing. Additionally, vaginal packing may be applied to support the area as needed. It is important to note that this code is specifically designated for non-obstetrical cases, distinguishing it from similar procedures performed for obstetrical or postpartum hematomas, which are coded differently.
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The procedure coded as CPT® 57023 is indicated for the management of non-obstetrical vaginal hematomas. These hematomas may arise from various causes, including:
The procedure for incision and drainage of a vaginal hematoma involves several critical steps, which are outlined as follows:
After the procedure, patients may require monitoring for any signs of complications, such as infection or continued bleeding. The physician will provide specific post-operative care instructions, which may include recommendations for activity restrictions and signs to watch for that would necessitate further medical attention. Recovery time can vary based on the individual and the extent of the hematoma, but patients are generally advised to follow up with their healthcare provider to ensure proper healing and address any concerns that may arise.
| Short Descr | I&D VAGINAL HEMATOMA NON-OB | Medium Descr | I&D VAGINAL HEMATOMA NON-OBSTETRICAL | Long Descr | Incision and drainage of vaginal hematoma; non-obstetrical (eg, post-trauma, spontaneous bleeding) | 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) | P5E - Ambulatory procedures - 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). | 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. | 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.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | GC | This service has been performed in part by a resident under the direction of a teaching physician | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| 2025-01-01 | Changed | Short Description punctuation changed. |
| 2011-01-01 | Changed | Short description changed. |
| 2001-01-01 | Added | First appearance in code book in 2001. |
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