Summary & Overview
CPT 57023: Vaginal Wall Hematoma Drainage with Foley Catheter
CPT code 57023 identifies surgical drainage of a vaginal wall hematoma with placement of a Foley catheter for ongoing drainage in a nonpregnant patient. This code captures a targeted gynecologic procedure used to evacuate a localized hematoma and maintain postoperative drainage, and it matters nationally because accurate coding supports appropriate surgical care documentation, resource use assessment, and payment for acute gynecologic interventions. Key payers typically involved in coverage for this procedure include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.
Readers will find clinical context for when 57023 is used, typical sites of service (ambulatory surgical centers and hospital operating rooms), and which payers commonly cover the service. The publication covers benchmarking and utilization patterns where available, notes common modifier usage and billing considerations, and summarizes relevant policy and documentation expectations that influence reimbursement and claims adjudication. Data gaps and unavailable elements from the input are noted explicitly where applicable. The content is intended for coders, billing managers, and clinicians who need a concise reference on the clinical scope and billing context of CPT code 57023 at a national level.
Billing Code Overview
CPT code 57023 describes a procedure in which the provider makes incisions and drains a hematoma from the vaginal wall and places a Foley catheter for continued drainage in a nonpregnant patient. This represents a gynecologic surgical drainage procedure addressing vaginal wall hematoma.
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Service type: Surgical drainage and catheter placement
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Typical site of service: Ambulatory surgical center or hospital operating room
Clinical & Coding Specifications
Clinical Context
A 34-year-old nonpregnant female presents to the emergency department with acute-onset perineal pain, swelling, and difficulty voiding after a forceps-assisted vaginal delivery two days prior. On examination there is a tender, fluctuant vaginal wall mass consistent with a postpartum vaginal wall hematoma causing urinary retention. Vital signs are stable but pain is significant despite oral analgesics. The surgical team prepares the patient for incision and drainage under regional or monitored anesthesia care. The workflow includes informed consent, verification of nonpregnant status, preprocedural antibiotics per facility protocol, positioning in lithotomy, direct visualization of the hematoma, incision and evacuation of clot, thorough hemostasis with cautery or suture ligation, placement of a transvaginal Foley catheter for continued drainage, and postoperative observation for recurrent bleeding and infection. Postoperative documentation includes operative note with estimated blood loss, hemostatic measures, catheter size and duration, complications, and discharge instructions regarding catheter care and signs of infection.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | No modifier (default) | Use when no specific modifier applies and routine reporting is appropriate |