CPT Code 57135 Excision Procedures on the Vagina

Accurate coding is essential in gynecology, especially for surgical procedures involving the vagina. CPT code 57135 is used for the excision of a vaginal cyst or tumor. This procedure is performed when a lesion within the vaginal wall causes symptoms, raises concern for malignancy, or requires removal for therapeutic purposes. Unlike biopsy codes, 57135 represents a definitive surgical excision and requires complete, precise documentation for correct billing.

This guide covers the code description, indications, guidelines, documentation requirements, reimbursement, and examples, all updated with 2025 AAPC and CMS standards to support OB-GYN providers in coding and billing with confidence.

CPT Code Description

• CPT Code: 57135
• Short Descriptor: Excision of vaginal cyst or tumor
• Long Descriptor: Excision of vaginal cyst or tumor, performed surgically.
• Category: Surgical Procedures on the Vagina – Excision Procedures

This code should be reported only when an actual cyst or tumor of the vaginal wall is removed surgically. It does not apply to drainage, marsupialization, or biopsy procedures.

Procedure Explanation

• What it is – A surgical excision of a cyst or tumor located within the vaginal wall or mucosa. The lesion is cut out and removed in its entirety, often with margins. Tissue is almost always sent to pathology for evaluation.
• What it treats – Conditions such as vaginal inclusion cysts, Gartner’s duct cysts (when excised), benign vaginal tumors, or other symptomatic lesions.
• Why it’s done – The purpose is therapeutic, not diagnostic. Excision removes diseased tissue, alleviates discomfort, and addresses the risk of malignant change.

Clinical Indications For CPT 57135

Providers report CPT 57135 when there is a medically necessary reason for excision. Typical scenarios include:

• Vaginal inclusion cysts – These cysts may enlarge and cause pain, infection, or dyspareunia. Excision under 57135 is reported when the cyst is surgically removed.
• Gartner’s duct cysts – If the cyst is excised, 57135 is the correct code. However, if marsupialization is performed, an unlisted procedure code may be required. Documentation must describe the surgical approach.
• Benign vaginal tumors – Tumors in the vaginal wall that bleed, enlarge, or cause discomfort are excised for therapeutic purposes. Accurate coding ensures payers recognize the service as medically necessary.
• Suspicious lesions – Any growths raising concern for malignancy require removal. In such cases, excision and pathology submission support the correct use of 57135.

Coding Guidelines & Billing Rules For CPT Code 57135

Correct coding ensures compliance and prevents denials. Key rules include:

• Excision only, not biopsy – If a lesion is excised, do not separately bill a biopsy code. Excision supersedes biopsy.
• Example: If a sample is taken and the rest of the lesion is removed in the same session, only the excision (57135) is billed.
• No marsupialization – Marsupialization (drainage with suturing to keep it open) is not coded with 57135. In some cases, it requires an unlisted code.
• The global surgical package – 57135 includes pre-operative, intra-operative, and post-operative care during the global period (commonly 90 days, but confirm with the payer).
• Bundling rules – If performed with other vaginal or pelvic surgeries, multiple procedure rules may apply. A modifier may be necessary to indicate distinct services.
• Place of service – Typically performed in outpatient hospitals or ambulatory surgical centers. Smaller cysts may be excised in an office setting.

Documentation Tips

Comprehensive documentation is crucial to justify medical necessity and secure reimbursement. Include:

• Patient symptoms/indication – Why the excision was needed (pain, bleeding, mass effect).
• Lesion details – Size, location (e.g., anterior vaginal wall), and type (cyst/tumor).
• Surgical description – Method of excision, depth, and margins.
• Pathology confirmation – Indicate that the specimen was sent to pathology.
• Post-op care – Any instructions or follow-up plans.

Tip: Vaginal procedures often trigger payer review. Strong, clear operative notes support claims and reduce audit risk.

Modifiers for CPT 57135

Modifiers clarify circumstances where 57135 is performed with other services:

• Modifier 59 – Distinct procedural service, when excision is separate from another vaginal surgery.
• Modifier 51 – Multiple procedures, if more than one surgical service is billed.
• Modifier 54 – Surgical care only, when another provider manages post-op.
• Modifier 55 – Postoperative management only.

Always ensure modifier use is backed by documentation.

Reimbursement & Payer Notes

Reimbursement rates vary, but CPT 57135 typically falls into a moderate-paying category for OB-GYN procedures.

• Average Medicare rates are regionally dependent; please refer to the current CMS Physician Fee Schedule for current information.
• Multiple surgery reductions – Apply if billed with additional procedures.
• Prior authorization – Some payers require prior approval for tumor excisions, especially for suspected malignancy.
• Global period – Often 90 days; during this time, related E/M services may not be separately billable.

Example Scenarios

• Case 1: Inclusion cyst
• A woman presents with a painful posterior vaginal wall inclusion cyst. The surgeon excises the cyst under local anesthesia. → Bill 57135.
• Case 2: Gartner’s duct cyst
• A lateral vaginal wall Gartner’s duct cyst is surgically removed. → Bill 57135 (if excised). Marsupialization would not be coded under 57135.
• Case 3: Vaginal tumor
• A gynecologist removes a suspicious tumor from the anterior vaginal wall and sends tissue to pathology. → Bill 57135, with documentation noting tumor size and pathology.

Why Choose BillingFreedom for OBGYN Billing?

Handling surgical billing codes, such as CPT 57135, can be challenging for many practices, as payers require accurate documentation, correct CPT/ICD-10 pairing, and an understanding of bundling rules. Minor errors may lead to claim denials or delayed payments, which can directly impact revenue flow. That’s where professional support becomes essential to keep your practice financially healthy while reducing administrative burden.

At BillingFreedom, we specialize in OB/GYN billing services with proven expertise in gynecological coding, compliance, and payer-specific rules. Our certified billing team ensures every claim is submitted clean, helping providers maximize reimbursements and minimize costly denials. With our streamlined approach, you can focus on delivering exceptional patient care while we handle the complexities of billing. Partnering with us means smoother revenue cycles, faster payments, and stress-free claim management for your OBGYN practice.

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