Summary & Overview
CPT 57415: Removal of Wedged Vaginal Foreign Body Under Anesthesia
CPT code 57415 represents the surgical removal of a foreign body that is wedged into the vaginal wall performed under anesthesia other than local. The code captures a focused gynecologic procedure that often requires an operating room or procedure suite and anesthesia support, making it relevant to facility billing, anesthesia services, and surgical specialty documentation. Nationally, accurate use of this code matters for clinical clarity, resource allocation, and appropriate reimbursement pathways for gynecologic procedural care.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the clinical context for 57415, typical sites of service, and payer considerations. The publication outlines common modifiers and billing patterns associated with procedural and anesthesia coordination, summarizes how payers commonly approach coverage for minor gynecologic operative procedures, and highlights documentation elements that support appropriate code selection.
This resource is intended to help coders, billing managers, and clinical documentation specialists understand when 57415 is the appropriate procedural code, what operational settings are typical, and which payer types are most commonly involved in adjudicating claims for this service. Data not available in the input.
Billing Code Overview
CPT code 57415 describes the removal of a foreign body that is wedged into the vaginal wall while the patient is under anesthesia other than local. This procedure is classified as a surgical removal of an embedded vaginal foreign body and typically requires anesthesia beyond local infiltration.
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Service type: Surgical foreign body removal (gynecologic)
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Typical site of service: Operating room or procedure/surgical suite under regional or general anesthesia
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Clinical & Coding Specifications
Clinical Context
A typical patient is a woman presenting to the emergency department or same-day surgical unit after insertion of a foreign object into the vagina that cannot be removed in the clinic due to patient discomfort, mucosal entrapment, or deep impaction. Examples include retained intravaginal devices, fractured condom or tampon fragments, small toys, or organic material that became lodged in the vaginal fornix. Initial evaluation includes history, focused pelvic exam, and bedside attempts at removal with topical or local anesthesia. If the object is tightly wedged, embedded in the vaginal wall, or the patient is unable to tolerate manipulation, the provider schedules removal in an operating room or procedure suite under general anesthesia or regional anesthesia (spinal/epidural) — i.e., anesthesia other than local. The workflow typically involves preoperative consent, anesthesia evaluation, patient positioning in dorsal lithotomy, sterile preparation, use of vaginal speculum and appropriate grasping or extraction tools (forceps, curettes, suction), possible limited sharp dissection if embedded, hemostasis, and postprocedure inspection for mucosal or deeper injury. Postoperative documentation includes the foreign body description, estimated duration of impaction, anesthesia type, instruments used, any complications, and discharge instructions. Usual sites of service are the hospital operating room, ambulatory surgery center, or emergency department procedure room with anesthesia support.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
23 | Unusual anesthesia | Use when procedure is performed under general anesthesia for a normally local procedure due to need for immobility or patient distress. |