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CPT 57400: Vaginal Dilation for Adhesions or Injury

CPT code 57400 represents a gynecologic operative procedure for gradual vaginal dilation when the vaginal canal is closed or narrowed by adhesions or injury. Nationally, this code identifies services intended to restore vaginal patency, often requiring procedural anesthesia and an operative setting. The code matters because it affects surgical case mix, reimbursement classification, and documentation requirements for procedures addressing vaginal stenosis or obliteration.

Key payers in the analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of clinical context for use of the code, common sites of service, typical payer considerations, and expected documentation points. The publication provides benchmarks where available, outlines relevant coding and billing considerations, and summarizes recent policy or coverage trends that influence payment and utilization nationally. Data not available in the input are identified explicitly where applicable. This summary is intended for coding professionals, billing managers, and clinical leaders who need a clear, national-level reference on CPT code 57400 and its operational implications.

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Billing Code Overview

CPT code 57400 describes a procedure in which a physician uses calibrated instruments to gradually dilate the vagina that is closed due to adhesion formation or injury. This service is a surgical procedure to restore or create a vaginal canal lumen by mechanical dilation.

Service type: Operative gynecologic procedure involving manual or instrument-assisted dilation.
Typical site of service: Ambulatory surgical center or hospital outpatient setting; may also occur in an operating room when performed with anesthesia.

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CPT 57400: Vaginal Dilation for Adhesions or Injury

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Billing Code Overview

Service type: Operative gynecologic procedure involving manual or instrument-assisted dilation.
Typical site of service: Ambulatory surgical center or hospital outpatient setting; may also occur in an operating room when performed with anesthesia.

Clinical & Coding Specifications

Clinical Context

A 32-year-old woman presents with progressive dyspareunia and inability to insert tampons following pelvic radiotherapy for cervical cancer two years prior. Examination demonstrates partial vaginal stenosis with scar bands and narrowing of the introitus. The gynecologist schedules a procedure for gradual mechanical dilation of the vagina under appropriate anesthesia using calibrated dilators to break adhesions and restore patency. Pre-procedure workflow includes informed consent, review of prior radiation and surgical history, targeted pelvic exam, pregnancy test if of childbearing potential, anesthesia evaluation, and documentation of baseline vaginal length and degree of stenosis. Intra-procedure steps include insertion of sequentially larger calibrated dilators with gentle, controlled pressure, lysis of superficial adhesions as needed, hemostasis, and topical estrogen or steroid application when indicated. Post-procedure care includes observation for bleeding or infection, discharge instructions on home dilation regimen, pain control, and scheduled follow-up to monitor healing and prevent re-adhesion.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when the dilation required markedly greater effort, time, or complexity than typical due to extensive scarring or adhesions.
`23`	Unusual anesthesia	Use when general anesthesia is required for an otherwise non-anesthetized procedure due to patient factors or anticipated pain.
`26`	Professional component	Use when reporting only the professional component of a service separated from technical component (rare for this procedure).
`52`	Reduced services	Use when the procedure is partially reduced or not completed for documented clinical reasons.
`53`	Discontinued procedure	Use when the procedure is started but discontinued due to extenuating circumstances or patient safety concerns.
`59`	Distinct procedural service	Use when another separately identifiable procedure is performed and should be reported in addition to the dilation.
`62`	Two surgeons	Use when two surgeons with distinct roles perform the procedure collaboratively.
`76`	Repeat procedure by same physician	Use when the same physician repeats the procedure later during the same postoperative period (if applicable).
`77`	Repeat procedure by another physician	Use when a different physician repeats the procedure during the same postoperative period.
`78`	Return to operating room for a related procedure during the postoperative period	Use when the patient requires a related unplanned reoperation for complications.
`79`	Unrelated procedure or service by the same physician during the postoperative period	Use when an unrelated procedure is performed during the global period.
`LT`	Left side	Use when laterality is reportable and the procedure is specific to the left side (not typically applicable to vaginal dilation but included when laterality is required in billing systems).
`RT`	Right side	Use when laterality is reportable and the procedure is specific to the right side (see note above).
`QX`	Qualified non-physician anesthetist with medical direction by physician	Use when a CRNA provides anesthesia under medical direction for the procedure.

Taxonomy Code	Specialty	Notes
261QM0800X	Obstetrics & Gynecology	General OB/GYN physicians who commonly perform vaginal procedures and dilations.
207V00000X	Female Pelvic Medicine & Reconstructive Surgery (Urogynecology)	Specialists managing complex vaginal stenosis, pelvic floor disorders, and surgical reconstruction.
207L00000X	Gynecologic Oncology	Gynecologic oncologists treating radiation-induced vaginal stenosis and post-oncologic reconstruction.
208D00000X	Colon & Rectal Surgery	Occasionally involved when adjacent perineal or rectal pathology affects vaginal access (consultative role).

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
Data not available in the input.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`57425`	Lysis of adhesions; vaginal (separate procedure)	Performed when dense intra-vaginal adhesions require operative lysis beyond simple graduated dilation; may be billed when more extensive adhesiolysis is documented.
`57420`	Vaginal procedures, diagnostic and operative; colpotomy, incision, or drainage procedures (less specific category)	May be performed in conjunction when additional minor operative vaginal interventions are required.
`57140`	Vaginoplasty, reconstruction of vagina and repair of pelvic floor defect	Performed for definitive reconstruction when dilation alone is insufficient to restore anatomy or function.
`58150`	Removal of intrauterine device, nonobstetrical	May be performed in the same encounter if device removal is indicated before dilation (workflow-related, not directly related).
`99499`	Unlisted evaluation and management service (if no specific code applies)	Rarely used for bundled or non-standard services associated with complex perioperative management when no specific CPT is appropriate.

CPT 57410: Examination of Female Genital Organs Under Anesthesia

CPT-57415-VAGINAL-FOREIGN-BODY-REMOVAL-ANESTHESIA

CPT 57415: Removal of Wedged Vaginal Foreign Body Under Anesthesia

Frequently Asked Questions

References

1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.

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Clinical & Coding Specifications

Clinical Context

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when the dilation required markedly greater effort, time, or complexity than typical due to extensive scarring or adhesions.
`23`	Unusual anesthesia	Use when general anesthesia is required for an otherwise non-anesthetized procedure due to patient factors or anticipated pain.
`26`	Professional component	Use when reporting only the professional component of a service separated from technical component (rare for this procedure).
`52`	Reduced services	Use when the procedure is partially reduced or not completed for documented clinical reasons.
`53`	Discontinued procedure	Use when the procedure is started but discontinued due to extenuating circumstances or patient safety concerns.
`59`	Distinct procedural service	Use when another separately identifiable procedure is performed and should be reported in addition to the dilation.
`62`	Two surgeons	Use when two surgeons with distinct roles perform the procedure collaboratively.
`76`	Repeat procedure by same physician	Use when the same physician repeats the procedure later during the same postoperative period (if applicable).
`77`	Repeat procedure by another physician	Use when a different physician repeats the procedure during the same postoperative period.
`78`	Return to operating room for a related procedure during the postoperative period	Use when the patient requires a related unplanned reoperation for complications.
`79`	Unrelated procedure or service by the same physician during the postoperative period	Use when an unrelated procedure is performed during the global period.
`LT`	Left side	Use when laterality is reportable and the procedure is specific to the left side (not typically applicable to vaginal dilation but included when laterality is required in billing systems).
`RT`	Right side	Use when laterality is reportable and the procedure is specific to the right side (see note above).
`QX`	Qualified non-physician anesthetist with medical direction by physician	Use when a CRNA provides anesthesia under medical direction for the procedure.

Taxonomy Code	Specialty	Notes
261QM0800X	Obstetrics & Gynecology	General OB/GYN physicians who commonly perform vaginal procedures and dilations.
207V00000X	Female Pelvic Medicine & Reconstructive Surgery (Urogynecology)	Specialists managing complex vaginal stenosis, pelvic floor disorders, and surgical reconstruction.
207L00000X	Gynecologic Oncology	Gynecologic oncologists treating radiation-induced vaginal stenosis and post-oncologic reconstruction.
208D00000X	Colon & Rectal Surgery	Occasionally involved when adjacent perineal or rectal pathology affects vaginal access (consultative role).

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
Data not available in the input.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`57425`	Lysis of adhesions; vaginal (separate procedure)	Performed when dense intra-vaginal adhesions require operative lysis beyond simple graduated dilation; may be billed when more extensive adhesiolysis is documented.
`57420`	Vaginal procedures, diagnostic and operative; colpotomy, incision, or drainage procedures (less specific category)	May be performed in conjunction when additional minor operative vaginal interventions are required.
`57140`	Vaginoplasty, reconstruction of vagina and repair of pelvic floor defect	Performed for definitive reconstruction when dilation alone is insufficient to restore anatomy or function.
`58150`	Removal of intrauterine device, nonobstetrical	May be performed in the same encounter if device removal is indicated before dilation (workflow-related, not directly related).
`99499`	Unlisted evaluation and management service (if no specific code applies)	Rarely used for bundled or non-standard services associated with complex perioperative management when no specific CPT is appropriate.

CPT 57410: Examination of Female Genital Organs Under Anesthesia

CPT-57415-VAGINAL-FOREIGN-BODY-REMOVAL-ANESTHESIA

CPT 57415: Removal of Wedged Vaginal Foreign Body Under Anesthesia

Frequently Asked Questions

References

1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.

Published by

Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.

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CPT 57400: Vaginal Dilation for Adhesions or Injury

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Billing Code Overview

OpenPayer

CPT 57400: Vaginal Dilation for Adhesions or Injury

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Billing Code Overview

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Related Diagnoses

Related CPT Codes

Related Codes

References

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Related Diagnoses

Related CPT Codes

Related Codes

References

CPT 57400: Vaginal Dilation for Adhesions or Injury

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Billing Code Overview

CPT 57400: Vaginal Dilation for Adhesions or Injury

Sign up for cpt 57400 policy alerts

Billing Code Overview

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Related Diagnoses

Related CPT Codes

Related Codes

What clinical situation and setting does CPT 57400 describe?

Which modifiers are commonly applicable to CPT 57400 and when should they be considered?

What related CPT codes might be billed with or instead of 57400?

Which specialties and taxonomy codes are most relevant for providers performing this procedure?

What key documentation elements should be included in the medical record for a CPT 57400 procedure?

References

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Related Diagnoses

Related CPT Codes

Related Codes

What clinical situation and setting does CPT 57400 describe?

Which modifiers are commonly applicable to CPT 57400 and when should they be considered?

What related CPT codes might be billed with or instead of 57400?

Which specialties and taxonomy codes are most relevant for providers performing this procedure?

What key documentation elements should be included in the medical record for a CPT 57400 procedure?

References