Accurate CPT coding is essential for OBGYN and urogynecology practices to ensure compliance, proper reimbursement, and reduced audit risk. CPT 57285 is reported when the physician performs a paravaginal defect repair, a complex reconstructive procedure designed to correct lateral detachment of the anterior vaginal wall from the pelvic sidewall. This defect contributes to cystocele formation, pelvic pressure, and urinary dysfunction.
As a reconstructive pelvic floor surgery, 57285 requires clear clinical documentation and precise coding to distinguish it from standard anterior colporrhaphy. This guide provides an in-depth overview of the procedure’s purpose, indications, documentation requirements, modifier use, and reimbursement guidance - fully aligned with CMS and AAPC 2025 standards to support compliant billing.
CPT 57285 – Description
Official Definition: “Paravaginal defect repair (including repair of cystocele, when performed); vaginal approach.”
This code represents the surgical correction of a lateral cystocele caused by detachment of the pubocervical fascia from the arcus tendineus fascia pelvis (white line). During this procedure, the surgeon reattaches the vaginal fascia to the pelvic sidewall to restore normal support to the bladder and anterior vaginal wall.
The vaginal approach (57285) differs from the abdominal approach (57425) - coding should reflect the surgical route. This repair often accompanies or follows a hysterectomy or prolapse repair, but is reportable separately when documentation confirms a distinct paravaginal defect and independent surgical effort.
When to Use CPT 57285
Use CPT 57285 when the physician performs a vaginal paravaginal defect repair to correct cystocele or pelvic floor laxity due to lateral fascial detachment. It’s appropriate when symptoms such as urinary incontinence, vaginal bulging, or pelvic discomfort are linked to structural fascial defects rather than simple central laxity.
Common clinical indications include:
- Lateral cystocele secondary to fascial detachment.
- Recurrent prolapse following prior anterior colporrhaphy.
- Pelvic organ prolapse after childbirth or hysterectomy.
- Symptomatic vaginal wall descent not corrected by midline repair alone.
Do not report 57285 for:
- Standard anterior colporrhaphy (use 57240).
- Abdominal paravaginal repair (use 57425).
- Vaginal vault suspension or enterocele repair (use 57282 or 57268, respectively).
Coding Guidelines and Bundling Considerations For CPT Code 57285
CPT 57285 includes repair of the cystocele when performed as part of the same operation, so separate reporting of 57240 is not appropriate for the same defect. If a hysterectomy or another prolapse procedure (such as posterior colporrhaphy) is performed concurrently, follow NCCI bundling edits to determine whether modifier 59 (or XS) is warranted.
This code has a 90-day global period, meaning postoperative care, routine follow-up, and suture removal are included. If another provider manages postoperative care, modifiers 54 and 55 should be applied accordingly.
Providers should ensure the operative note clearly differentiates a paravaginal defect (lateral separation of the vaginal fascia from the pelvic wall) from a midline fascial defect (central weakness). Misidentification can lead to incorrect coding and claim denials.
Reimbursement Information For CPT Code 57285 (2025 Updates)
Under the 2025 Medicare Physician Fee Schedule, CPT 57285 is categorized as a major reconstructive gynecologic surgery with a 90-day global period. It is reimbursed at a higher rate than a standard anterior repair due to its complexity. Reimbursement amounts vary based on region, site of service (hospital vs. ASC), and payer contract terms.
Because this surgery often requires operative anesthesia and inpatient or ASC settings, preauthorization is frequently required by commercial and Medicare Advantage plans. Always confirm payer policy requirements before the procedure to avoid payment denials or delayed claims.
Applicable Modifiers For CPT Code 57285
Modifiers help clarify the surgical circumstances:
- Modifier 59 (or XS) – Use when performed as a distinct procedure, separate from another major pelvic surgery.
- Modifier 51 – Apply when multiple unrelated procedures are performed in the same session.
- Modifiers 54/55 – Used when surgical and postoperative management are split between providers.
- Modifier 52 – Apply if the procedure is partially reduced or incomplete.
Laterality modifiers are not used for vaginal procedures. Always confirm payer-specific modifier acceptance before claim submission.
Documentation Requirements For CPT Code 57285
Precise documentation is crucial for supporting medical necessity and ensuring compliance. Operative reports should include:
- Preoperative diagnosis with details of lateral fascial detachment or paravaginal defect.
- Description of cystocele extent and associated symptoms.
- Clear operative technique, including reattachment of pubocervical fascia to the arcus tendineus.
- Notation of approach (vaginal).
- Presence or absence of concurrent repairs (e.g., hysterectomy, posterior repair).
- Use of grafts or sutures and closure details.
- Postoperative plan and patient counseling.
Comprehensive operative notes protect against payer denials and audits, ensuring the claim accurately reflects the procedure’s complexity.
Example Scenarios
Scenario 1: A patient with recurrent cystocele after previous anterior colporrhaphy undergoes vaginal paravaginal defect repair with fascial reattachment. → Report CPT 57285.
Scenario 2: During vaginal hysterectomy, the surgeon identifies a lateral defect and performs paravaginal repair as a separate step, well-documented in the operative note. → Report hysterectomy code plus 57285 with modifier 59 if distinct.
Scenario 3: A simple midline cystocele repair without fascial reattachment. → Report 57240, not 57285.
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Related ICD-10-CM Codes
ICD-10-CM Codes
N39.491 - Coital incontinence
N39.492 - Postural (urinary) incontinence
N81.0 - Urethrocele
N81.10 - Cystocele, unspecified
N81.11 - Cystocele, midline
N81.12 - Cystocele, lateral
N81.2 - Incomplete uterovaginal prolapse
N81.3 - Complete uterovaginal prolapse
N81.4 - Uterovaginal prolapse, unspecified
N81.6 - Rectocele
N81.81 - Perineocele
N81.83 - Incompetence or weakening of rectovaginal tissue
N81.85 - Cervical stump prolapse
N81.89 - Other female genital prolapse
N81.9 - Female genital prolapse, unspecified
N99.3 - Prolapse of vaginal vault after hysterectomy
O70.20 - Third degree perineal laceration during delivery, unspecified
O70.21 - Third degree perineal laceration during delivery, IIIa
O70.22 - Third degree perineal laceration during delivery, IIIb
O70.23 - Third degree perineal laceration during delivery, IIIc