Summary & Overview
CPT 57111: Vaginectomy with Paravaginal Tissue Removal
CPT code 57111 denotes complete removal of the vaginal wall with excision of paravaginal tissues, a major pelvic reconstructive or extirpative procedure. Nationally, this code represents high-complexity gynecologic surgery typically performed in hospital operating rooms or ambulatory surgical centers. It is relevant to surgical billing, anesthesia planning, post-operative care pathways, and payer coverage determinations.
Key payers in the national context include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of where this service is typically provided, how it is categorized clinically, and what types of benchmarks and policy elements commonly apply to major pelvic surgeries. The publication summarizes expected clinical settings, the procedural scope implied by the code, common modifier usage (listed separately), and points of attention for coding and claims submission.
This resource is intended to inform coding professionals, revenue cycle staff, and clinical administrators about the clinical meaning of the code, typical sites of service, and the payer landscape to which this service most often relates. Data not available in the input is clearly noted in relevant sections.
Billing Code Overview
CPT code 57111 describes a surgical procedure in which the provider removes the entire vaginal wall with removal of paravaginal tissues. This service is a major pelvic reconstructive surgery involving extensive excision of vaginal and adjacent supportive tissues.
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Service type: Major pelvic reconstructive/extirpative vaginal surgery
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Typical site of service: Hospital operating room or ambulatory surgical center, depending on patient condition and clinical setting
Clinical & Coding Specifications
Clinical Context
A typical patient is a postmenopausal woman presenting with symptomatic pelvic organ prolapse involving the anterior and/or posterior vaginal walls with significant paravaginal support defects. She reports vaginal bulge, pelvic pressure, urinary frequency or retention, and difficulty with sexual activity. Conservative measures (pelvic floor physical therapy, pessary) were attempted or contraindicated. After evaluation with pelvic exam, POP-Q staging, and relevant imaging or urodynamic testing as indicated, the surgical plan is for an extensive vaginal wall excision with removal of paravaginal tissues to correct prolapse and remove redundant or diseased vaginal mucosa.
The clinical workflow includes preoperative assessment (history, physical, informed consent), optimization of medical comorbidities, preoperative antibiotics and DVT prophylaxis per facility protocol, anesthesia evaluation (general, regional, or monitored anesthesia care), intraoperative cystoscopy as indicated, performance of the vaginal wall excision with paravaginal tissue removal, hemostasis, possible concomitant procedures (e.g., hysterectomy, pelvic floor repair, sling placement) documented separately, postoperative recovery with pain control and discharge instructions, and outpatient follow-up for wound healing and assessment of prolapse repair success.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | No modifier — standard reporting | Use when no additional modifier applies and the procedure is billed ordinarily. |