Summary & Overview
CPT 57210: Repair of Vaginal Wall or Perineal Laceration, Nonobstetric
CPT code 57210 identifies nonobstetric repair of vaginal wall and/or perineal lacerations — a focused soft-tissue suturing procedure performed to restore anatomy and control hemorrhage. Nationally, this code matters because it captures a discrete surgical service across multiple ambulatory and hospital outpatient settings and influences procedure-level billing, quality measurement, and coding accuracy for gynecologic and emergency care. Key payers in typical analyses include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will learn the clinical scope of the code, typical sites of service, common billing modifiers associated with surgical procedures, and payer coverage patterns where available. The publication also outlines benchmarks and policy considerations relevant to coding consistency, documentation requirements for surgical repair, and how this code is differentiated from obstetric laceration repair codes. Data not available in the input is noted where applicable, and the piece focuses on national implications for coding, billing, and clinical documentation rather than state-specific rules.
Billing Code Overview
CPT code 57210 describes the surgical repair of a laceration of the vaginal wall and/or perineum when the injury is not related to childbirth or pregnancy. This procedure involves suturing soft-tissue tears in the vaginal or perineal mucosa and underlying tissue to restore anatomy and stop bleeding.
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Service type: Minor surgical soft-tissue repair
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Typical site of service: Ambulatory surgical center, hospital outpatient department, or office-based surgical setting
Clinical & Coding Specifications
Clinical Context
A 28-year-old female presents to the emergency department after sustaining a non-obstetric vaginal laceration during a fall onto a foreign object. She is hemodynamically stable, has localized vaginal bleeding, and an isolated laceration of the vaginal wall and perineum not related to childbirth or pregnancy. After focused history, pelvic exam, and local infiltration of anesthetic in the procedure room or minor procedure suite, the gynecologist or emergency medicine physician performs repair using layered closure with absorbable sutures to reapproximate the vaginal mucosa and perineal tissues. The clinical workflow includes pre-procedure consent, analgesia or sedation as indicated, irrigation and debridement, hemostasis, layered suturing of the vaginal wall and perineum, post-repair inspection, tetanus status assessment, and discharge instructions with follow-up to gynecology if needed. Typical sites of service are the emergency department, outpatient minor procedure suite, urgent care with appropriate capabilities, or ambulatory surgery center if sedation or exploratory exam under anesthesia is required. The service type is an operative soft-tissue procedure (repair) of the vulvovaginal/perineal region for a non-obstetric laceration.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, separately identifiable evaluation and management service on the same day as a procedure | Use if a distinct E/M is performed prior to repair (Note: 25 is not in the provided modifier list; not included) |
26 | Professional component | Use when billing only the professional component of a service (e.g., interpretation component separated) |
50 | Bilateral procedure | Use if identical repairs are performed bilaterally on paired structures (rare for vaginal wall) |
51 | Multiple procedures | Use when multiple distinct procedures are billed on the same date alongside the repair |
52 | Reduced services | Use when the repair is partially reduced or not completed as originally planned |
53 | Discontinued procedure | Use when the procedure is terminated due to patient-related or clinical reasons before completion |
59 | Distinct procedural service | Use to indicate a distinct procedure or service not ordinarily performed on the same day as other services by the same provider |
62 | Two surgeons | Use when two surgeons of different specialties perform distinct portions of the repair jointly |
66 | Surgical team | Use when a surgical team approach is employed for complex repairs requiring multiple surgeons |
78 | Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period | Use if a patient requires an unplanned return to the OR for revision or re-bleeding management post-repair |
79 | Unrelated procedure or service by the same physician during the postoperative period | Use if an unrelated procedure is performed during the global period (Note: 79 is not in the provided list; not included) |
80 | Assistant surgeon | Use when an assistant surgeon provides significant assistance during the repair |
81 | Minimum assistant surgeon | Use when a minimally involved assistant surgeon participates |
82 | Assistant surgeon (when qualified resident surgeon not available) | Use when an assistant surgeon is necessary and no qualified resident is available |
73 | Discontinued outpatient procedure prior to anesthesia administration | Use if the outpatient repair is cancelled before anesthesia is given (applicable in ambulatory settings) |
| Taxonomy Code | Specialty | Notes |
|---|---|---|
207V00000X | Obstetrics & Gynecology | Most common specialty performing vaginal and perineal soft-tissue repairs in non-obstetric settings |
206Q00000X | Emergency Medicine | Frequently performs acute laceration repair in the ED or urgent care setting |
2080P0207X | General Surgery | May perform perineal or adjacent soft-tissue repairs in trauma settings |
2084P0800X | Family Medicine | May perform repairs in outpatient or urgent care clinics depending on training |
208D00000X | Plastic Surgery | Involved for complex perineal reconstruction or secondary repair needs |
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
| Data not available in the input. |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
12032 | Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (approx 2.5 cm to 7.5 cm) | May be used for intermediate-layer soft-tissue repairs in other anatomic sites; included as a comparable repair technique when larger perineal/labial lacerations require layered closure |
13132 | Secondary repair, complicated or extensive repair of acute and chronic wounds; scalp, arms and/or legs, 2.6 cm to 7.5 cm | Used when complex or secondary repairs are required; analogous for extensive perineal/vaginal tissue reconstruction following initial repair failure |
57220 | Repair of perineal and/or vaginal laceration and/or episiotomy, complex (eg, extensive repair) not relating to childbirth | Closely related; indicates a more complex repair of the same anatomic region and may be used when tissue loss or complex reconstruction is required |
99281 | Emergency department visit, problem-focused | Common E/M level used in ED prior to procedural repair when minimal complexity evaluation is performed |
99284 | Emergency department visit, moderate complexity | Represents a higher-complexity ED evaluation often performed before procedural repair requiring urgent diagnosis and treatment |
99152 | Moderate sedation services provided by the same physician performing the procedure (initial 15 minutes) | Used when the provider administers moderate sedation for pain control during repair in a monitored setting |
36415 | Collection of venous blood by venipuncture | May be performed pre-procedure for labs or crossmatch in trauma settings |
99024 | Postoperative follow-up visit global surgery unrelated to E/M coding (historical usage) | Used for postoperative follow-up related to the repair in certain billing contexts (use per payer rules) |