Urology Coding Alert

Question: What codes should I report for Le Fort colpocleisis with high perineorrhaphy and cystoscopy?

Colorado Subscriber

Answer: You should report 57120 (Colpocleisis (Le Fort type)) for the Le Fort procedure, which narrows and shortens the vagina. Colpocleisis is a procedure to treat pelvic organ prolapse. The cystoscopy and perineorrhaphy are bundled into 57120, so they are not separately billable.

Don’t miss: The code descriptor mentions Le Fort as an example of a procedure for which this code can be reported. However, the code is not exclusive to the Le Fort procedure. Code 57120 can be used for any colpocleisis procedure. Although this procedure is usually performed by gynecologists, urogynecologists will perform this procedure as well.

According to Stephanie Storck, CPC, CPMA, CUC, CCS-P, ACS-UR, longtime urology coding expert and consultant in Glen Burnie, Maryland, “The Le Fort procedure is frequently carried out by the provider for older patients who have severe prolapse, are not sexually active, and still possess

their uteruses. This surgery closes the vaginal canal so that intercourse is no longer possible. Also, providers will perform a total colpocleisis on patients who do not have a uterus but have complete vaginal vault prolapse.”