Summary & Overview
CPT 57109: Upper Vaginectomy with Pelvic and Para‑aortic Lymph Node Biopsy
CPT code 57109 represents an extensive gynecologic oncologic operation: removal of the upper half of the vagina with paravaginal tissue and bilateral pelvic lymph node dissection, plus para‑aortic lymph node biopsy. This code captures high‑acuity surgical care with substantial implications for operative time, perioperative resources, and postoperative management. Nationally, procedures coded with 57109 are relevant to hospitals, oncology surgeons, and payers because they often drive inpatient utilization, complexity-based reimbursement, and guideline‑driven oncologic staging.
Key payers addressed in the analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of clinical intent and service setting, plus benchmarking context where available. The publication outlines coding and billing considerations, typical sites of service, and the clinical scenarios that commonly prompt use of 57109 (major vaginal resection with pelvic and para‑aortic nodal assessment).
This summary prepares clinicians, coding professionals, and policy analysts to understand where 57109 fits within gynecologic oncology practice, what payers commonly encounter when authorizing and adjudicating these claims, and what further details (benchmarks, payer policies, and related codes) the full publication examines. Data not available in the input will be noted in the detailed sections.
Billing Code Overview
CPT code 57109 describes a surgical procedure in which the provider removes the upper half of the vagina along with paravaginal tissue and performs bilateral pelvic lymphadenectomy, with biopsy of para‑aortic lymph nodes. This procedure is a major gynecologic oncologic operation involving resection of vaginal tissue and comprehensive pelvic and para‑aortic lymph node assessment.
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Service type: Major gynecologic oncologic surgery
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Typical site of service: Hospital operating room (inpatient or same‑day admission when clinically indicated)
Data not available in the input for payers, associated taxonomies, and specific ICD‑10 diagnoses.
Clinical & Coding Specifications
Clinical Context
A typical patient is a postmenopausal woman referred to gynecologic oncology for a suspected vaginal or lower uterine malignancy with regional lymphatic spread. Preoperative assessment includes history, pelvic exam, imaging with pelvic MRI or CT, and discussion of risks including bleeding, infection, ureteral injury and lymphedema. The procedure removes the upper half of the vagina with paravaginal tissue and performs bilateral pelvic lymphadenectomy with selective para‑aortic lymph node biopsy under general anesthesia. Typical workflow: preoperative consent and staging, operating room with gynecologic oncology team and anesthesia, intraoperative pathology as indicated, placement of drains as needed, postoperative recovery with hospital observation for pain control and monitoring for complications, and outpatient follow‑up for wound check, pathology review, and adjuvant therapy planning (radiation or systemic therapy) based on final pathology.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | When there is substantially greater work than typical for the procedure due to complexity or extensive adhesions |
50 | Bilateral procedure |