Urology Coding Alert

Hint: Pay attention to other services performed during the same session.

Treating a rectocele isn’t uncommon in a urology practice, but you still have a few things to consider when making your code selection. Read on for expert advice on reporting the situation, plus tips on how to distinguish rectoceles from other conditions that might sound similar.

Step 1: Know What a Rectocele Is

A rectocele is defined as a prolapse (or displacement) of the wall between the rectum and vagina, with a portion of the rectum bulging into the vagina. The condition usually develops after the wall is damaged during a vaginal delivery, though symptoms might not appear until many years later. Rectoceles are more commonly seen in older women who are going through menopause.

Many women with posterior vaginal prolapse also experience prolapse of other pelvic organs such as the bladder, anterior prolapse, cystocele, or uterus.

Nonsurgical treatment of a rectocele can involve intensive pelvic floor training exercises, biofeedback training, and sessions with nutritionists about avoiding constipation or with physical therapists to learn how to correctly perform Kegel exercises.

Terminology check: Although they sound similar, don’t confuse a rectocele with an enterocele. A rectocele occurs in the back wall of the vagina between the vagina and the rectum. An enterocele repair, by contrast, refers to a small bowel prolapse that occurs when the small bowel pushes against and moves the upper back wall of the vagina.

Step 2: Learn the Coding Options

If the urologist determines that the patient needs surgery to correct a rectocele, your code choice will depend partly on whether other defects are also present.

For a rectocele repair, submit one of three codes, depending on whether you’re reporting a single repair or a combination repair:

• 57250 (Posterior colporrhaphy, repair of rectocele with or without perineor­rhaphy)
• 57260 (Combined anteroposterior colporrhaphy, including cystoure­throscopy, when performed)
• 57265 (… with enterocele repair).

If the surgeon reinforces the vaginal wall with mesh material, include add-on code +57267 (Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, posterior compartment), vaginal approach (List separately in addition to code for primary procedure)) on the claim. 

However, remember the FDA has recently removed this mesh from the marketplace, reminds Michael A. Ferragamo, MD, clinical assistant professor of urology, State University of New York Stony Brook. “This mesh placement has been discontinued in the repairs and no longer performed by many urologists, gynecologists, or urogynecologists,” he says.

Tip: The term “colporrhaphy” in the descriptors above refers to surgical repair of a defect in the vaginal wall. During the procedure, the urologist removes extra vaginal tissue from the posterior wall and narrows the vaginal canal, says Melanie Witt, RN, MA, an independent coding consultant based in Guadalupita, N.M.

Step 3: Be Wary of Combination Services

As with many surgical code options, some might include more than one specific service.

Code 57250, for example, represents the repair of a rectocele with or without a perineorrhaphry and includes a posterior colporrhaphy. In contrast, 45560 (Repair of rectocele [separate procedure]) is for the repair of a rectocele using a perirectal approach without a posterior colporrhaphy. This latter approach is usually performed by a colorectal or general surgeon. The former is usually performed by a urologist, gynecologist, or urogynecologist.

Caution: Code 45560, which is listed in CPT^®’s Digestive System/Surgery section under Rectum, has slightly higher relative value units (RVUs) than the posterior colporrhaphy code 57250 (45560 has facility RVUs of 19.77 versus 17.04 RVUs for 57250). Be careful to bill the correct rectocele repair code based on the approach used and avoid billing an incorrect procedure code.

How to tell: According to experts, if the procedure contains a posterior colporrhaphy, the operative report usually will describe the following elements: a midline incision of the posterior vaginal wall and perineum separation of the vaginal skin from the underlying fascia plication (folding and tacking down with sutures) of the rectovaginal fascia excision of any excess fascia, and plastic repair of the perineum involving suturing together the levator and perineal muscles when indicated.

The procedure described by 45560 is a perirectal approach with the rectocele predominately herniating through the anal canal. The physician dissects the rectocele from the surrounding structures and plicates the rectum to the surrounding fascia to close the defect. Usually, a general surgeon or a colorectal surgeon performs this procedure to correct a problem often associated with fecal incontinence.

Step 4: Choose the Most Accurate Diagnosis

Diagnosis assignment will depend on the details in your provider’s documentation. Your most common options for rectocele and associated conditions include:

• N81.6 (Rectocele)
• N81.11 (Cystocele, midline)
• N81.12 (Cystocele, lateral)
• N81.5 (Vaginal enterocele).