Summary & Overview
CPT 57335: Vaginoplasty Using Existing Tissue
CPT code 57335 covers surgical creation of a vaginal canal using the patient’s existing tissue. The procedure is used in contexts including gender-affirming surgery and reconstruction for intersex patients whose anatomy does not conform to binary sex classifications. Nationally, this code is relevant to surgical practice patterns, payer coverage policies for gender-affirming and reconstructive care, and facility planning for operative services.
Key payers addressed in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise clinical context for the procedure, typical sites of service, and which major payers are commonly involved in coverage determinations. The publication summarizes reimbursement benchmarks where available, highlights policy developments affecting authorization and coverage, and outlines coding considerations for documentation and billing workflows.
This material is intended for revenue cycle managers, surgical program administrators, and policy analysts seeking a national overview of how CPT code 57335 is used in clinical and payer contexts. Data not available in the input will be identified as such in relevant sections.
Billing Code Overview
CPT code 57335 describes a surgical procedure in which the provider uses existing tissue to create a vaginal canal for the patient. This procedure is typically performed as part of gender-affirming surgery or reconstruction for individuals with intersex variations whose reproductive or sexual anatomy does not align with a binary male or female classification.
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Service type: Genital reconstruction / vaginoplasty using existing tissue
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Typical site of service: Inpatient or outpatient surgical setting (operating room)
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A typical patient is an adolescent or adult presenting for creation of a vaginal canal using existing tissue (vaginoplasty using local tissue). The indication may be congenital genital difference (e.g., intersex anatomy with absent or underdeveloped vaginal canal), post-traumatic or post-infectious vaginal stenosis, or gender-affirming genital surgery where local tissue is preferred. Preoperative evaluation includes medical history, psychosocial assessment, informed consent, hormone therapy review if applicable, pelvic exam, imaging as indicated, and anesthetic clearance.
The clinical workflow: outpatient consultation and counseling, preoperative planning with surgical consent and documentation of diagnosis codes, same-day admission to an ambulatory surgical center or hospital operating room (typical site of service: OR at hospital or ambulatory surgical center). General anesthesia is commonly used. The surgeon creates a neovaginal canal by mobilizing perineal or vulvar tissue (skin flaps, mucosal advancement, or inversion techniques) and establishes a patent cavity often with a stent or packing. Postoperative care includes pain control, antibiotics as indicated, wound care instructions, dilation protocol to maintain patency, and scheduled follow-up visits for wound checks and functional assessment. Documentation should include procedure details, tissue source, closure technique, drains or stents placed, estimated blood loss, complications, and postoperative instructions.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 |