Stress urinary incontinence can significantly affect a patient’s daily activities and quality of life, especially when caused by urethral hypermobility. CPT code 57289 is used when a physician performs the Pereyra procedure, a vaginal surgical technique designed to restore bladder neck support.

In this technique, a needle suspension method is used to lift and secure the urethra, and to treat anterior vaginal wall defects. It is native tissue repair without the use of synthetic mesh, and provides an alternative for patients who don't want to use a mesh during surgery.

CPT Code 57289 Description

The Pereyra procedure is a vaginal needle suspension procedure for SUI that is performed under CPT code 57289. Anterior colporrhaphy is part of this technique used in surgical repair.

The technique involves placing sutures from the periurethral tissues through the retropubic space and securing them to the rectus fascia or anterior abdominal wall to support the bladder neck.

This code is distinct from:

57288 – Sling operation for stress incontinence
57240 – Anterior colporrhaphy (performed alone)
57284/57285 – Paravaginal defect repair

Common clinical indications include:

Stress urinary incontinence with urethral hypermobility
Mild-to-moderate cystocele requiring repair
Patients seeking non-mesh surgical treatment
Cases where a traditional sling procedure is not preferred

Because anterior colporrhaphy is included, it should not be billed separately when performed with this procedure.

How the Procedure Is Performed

The Pereyra procedure is typically performed in an outpatient or ambulatory surgical setting under regional or general anesthesia.

The procedure generally includes:

Patient positioning and administration of anesthesia
Vaginal incision to reach periurethral tissues
Placement of sutures through the retropubic space
Attachment of sutures to the rectus fascia or anterior abdominal wall
Elevation and stabilization of the bladder neck and urethra
Performance of anterior colporrhaphy to repair cystocele
Hemostasis and closure of the incision

This approach provides urethral support using native tissue without the use of synthetic materials.

Applicable Modifiers for CPT Code 57289

To ensure accurate billing and reimbursement, modifiers are important to use:

Modifier 51 – Multiple procedures during the same session
Modifier 59 / XU – Distinct procedural service when unbundling is necessary
Modifier 22 – Increased procedural services for complex cases
Modifier 57 – Decision for surgery associated with an E/M service

Use of appropriate modifiers will help limit denials and promote proper reimbursement.

Documentation Requirements for CPT Code 57289

Completeness of documentation is crucial to correct coding. The operative report should have:

Diagnosis of stress urinary incontinence with urethral hypermobility
Description of the Pereyra needle suspension technique
Placement of sutures from periurethral tissue to the rectus fascia
Confirmation of anterior colporrhaphy performed
Any additional procedures conducted during the session
Type of anesthesia administered
Intraoperative findings and complications
Cystoscopy findings, if performed

Clear documentation ensures compliance and supports medical necessity.

Reimbursement and Billing Insights for CPT Code 57289

CPT 57289 is a major surgical procedure, with a 90-day global period, which includes routine post-surgical care.

Key billing considerations include:

Avoid billing anterior colporrhaphy (57240) separately, as it is included
Reviewing NCCI edits when combined with other prolapse or repair procedures
Applying modifiers appropriately when multiple procedures are performed
Ensuring documentation clearly supports the needle suspension technique

Reimbursement is generally moderate and may be lower than newer sling procedures, but it remains valid when properly documented.

BillingFreedom Expertise in OBGYN Medical Billing for Incontinence Procedures

Denials are likely to occur when coding and documentation are not precise or detailed in procedures such as the Pereyra technique to ensure accurate reimbursement. Failure to accurately report the CPT 57289 or to include the required details of the procedure will affect your revenue and compliance.

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