Urology Coding Alert

Watch for coding differences between rectocele and enterocele repairs.

Performing a rectocele repair in a urology practice is not unusual. However, there are several factors to consider when choosing your code. Continue reading for professional guidance on documenting this scenario, as well as advice on differentiating rectoceles from other conditions that may seem similar.

Tip 1: Understand What a Rectocele Is

A rectocele is characterized as a prolapse or shift of the wall separating the rectum and vagina, causing a part of the rectum to protrude into the vagina. This condition typically occurs after the wall is injured during vaginal childbirth, although symptoms may not manifest until much later. Rectoceles are more frequently observed in older women undergoing menopause.

It’s not uncommon for women with posterior vaginal prolapse to also have prolapses of other pelvic organs such as the bladder, anterior prolapse, cystocele, or uterus. Nonsurgical management of a rectocele may include rigorous pelvic floor training exercises, biofeedback training, consultations with nutritionists to prevent constipation, or sessions with physical therapists to learn the proper way to do Kegel exercises.

Tip 2: Review Your Choice of Codes

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.

Note: The term “colporrhaphy” in the descriptors below 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.

For a rectocele repair, you’ll choose from one of the codes below, depending on whether you’re reporting a single repair or a combination repair:

• 45560 (Repair of rectocele (separate procedure))
• 57250 (Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy)
• 57260 (Combined anteroposterior colporrhaphy, including cystourethroscopy, when performed)

Remember: If the surgeon reinforces the vaginal wall with prosthetic mesh, 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.

Tip 3: Check Your Terms

While their names may be similar, do not mix up a rectocele with an enterocele or a cystocele. An enterocele repair is normally performed by an ob/gyn as a separate procedure and would be coded as 57270 (Repair of enterocele, abdominal approach (separate procedure)).

A cystocele is a prolapse of the anterior vaginal wall. If the urologist uses an open approach to repair this, report 57284 (Paravaginal defect repair [including repair of cystocele, if performed]; open abdominal approach). For the vaginal approach, report 57285 (Paravaginal defect repair [including repair of cystocele, if performed]; vaginal approach). For a laparoscopic approach, use 57423 (Paravaginal defect repair [including repair of cystocele, if performed], laparoscopic approach).

Tip 4: Watch for Combination Services

Like many surgical codes, a lot of rectocele repair codes encompass multiple services. For instance, 57250 signifies rectocele repair, possibly with a perineorrhaphy, and includes a posterior colporrhaphy. However, 45560 is for rectocele repair only using a perirectal approach without a posterior colporrhaphy. The most common surgical correction method is the transvaginal rectocele repair, also known as a posterior repair. This procedure is performed by accessing the rectocele via the vagina. It provides an opportunity to fix not only the rectocele but also a thinned perineum and an enlarged vaginal opening. One of the main benefits of this method is that it does not interfere with any tissue in the rectal area.

Note: Code 45560 has slightly higher relative value unites (RVUs) than code 57250 (20.65 vs 18.50). Ensure to bill the correct rectocele repair code based on the approach used to avoid incorrect procedure coding and missing out on additional revenue.

Tip 5: Find the Correct 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)

Be aware of recent changes: Beginning Oct. 1, 2023, ICD-10-CM changed the Excludes2 note underneath N81.6 (Rectocele) to “Excludes1: rectocele with prolapse with uterus (N81.2-N81.4).”