Summary & Overview
CPT 57110: Complete Removal of Vaginal Wall
CPT code 57110 denotes complete removal of the vaginal wall, a major gynecologic surgical procedure used in select clinical situations. Nationally, this code represents a high-acuity operative service with implications for facility resource use, perioperative management, and payer coverage determinations. It is relevant for hospitals, ambulatory surgical centers, and payers assessing authorization and bundling policy for complex pelvic surgery.
Key payers addressed in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of the clinical context for 57110, typical sites of service, and the types of clinical scenarios that prompt use of the code. The publication presents national benchmarks for service utilization and payment patterns where available, summarizes relevant policy considerations that affect coverage and billing, and highlights documentation elements commonly referenced by payers for claim adjudication.
This summary aims to orient clinicians, coding staff, and policy analysts to the clinical meaning and billing implications of CPT code 57110, providing the context needed to interpret utilization patterns and payer rules at a national level.
Billing Code Overview
CPT code 57110 describes the surgical removal of the entire vaginal wall. This procedure is a major gynecologic surgical service involving full excision of vaginal tissues and is performed in operative settings.
Service Type: Major gynecologic surgery
Typical Site of Service: Operating room in an inpatient or outpatient surgical facility
Clinical & Coding Specifications
Clinical Context
A 62-year-old female with symptomatic, full-thickness pelvic organ prolapse and severe vaginal wall prolapse presents for surgical management. She reports pelvic pressure, difficulty with hygiene, recurrent ulceration of exposed vaginal mucosa, and urinary symptoms refractory to conservative measures. Preoperative evaluation includes pelvic exam confirming complete eversion of the vaginal wall, review of medical comorbidities (cardiac clearance due to hypertension and COPD), imaging as indicated, informed consent addressing risks of bleeding, infection, sexual dysfunction, and need for possible concurrent procedures. On the day of surgery the patient is admitted to an ambulatory surgery center or hospital operating room under general or regional anesthesia. The operative team performs a total vaginectomy — removal of the entire vaginal wall — with attention to hemostasis, possible placement of drains, and reconstruction or closure as indicated. Postoperative workflow includes PACU monitoring, pain control, antibiotics as indicated, discharge planning with activity restrictions, wound care instructions, and follow-up visits for wound checks and assessment of urinary/sexual function.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
11 | Surgical procedure performed by same physician who typically performs the procedure | Use when the primary surgeon performs the listed operation without another surgeon taking over. |