CPT Code 57415 Complete Billing & Coding Guide for Manipulation Procedures on the Vagina

Accurate CPT coding is essential for OBGYN providers to ensure compliance, prevent denials, and receive correct reimbursement. CPT 57415 is reported when a surgeon performs a laparoscopic colpopexy, a minimally invasive suspension of the vaginal apex used to correct vaginal vault or uterovaginal prolapse.

This guide provides comprehensive information on how to report CPT 57415 accurately, including coding rules, indications, modifier usage, documentation requirements, and reimbursement details in accordance with AAPC and CMS 2025 guidelines.

CPT 57415 – Description

Official Definition: “Laparoscopy, surgical, colpopexy (suspension of vaginal apex).”

This procedure is performed to restore vaginal support in patients with apical prolapse. Through small laparoscopic incisions, the surgeon identifies the vaginal cuff or cervix and secures it to a firm pelvic structure, such as the sacral promontory or uterosacral ligament. Mesh or permanent sutures may be used for fixation.

Report CPT 57415 only when the laparoscopic approach is used. If the same repair is done via an open abdominal incision, report CPT 57280 instead.

When to Use CPT 57415

Use CPT 57415 when a laparoscopic colpopexy is performed to correct vaginal vault or uterovaginal prolapse.

Common indications include:

• Vaginal vault prolapse after hysterectomy.
• Uterovaginal prolapse with apical descent.
• Recurrent prolapse following prior vaginal repair.
• Pelvic pressure or bulge symptoms due to loss of apical support.

Do not use 57415 if the repair is transvaginal (use 57282) or open abdominal (use 57280). When performed during a laparoscopic hysterectomy, report it separately only if documentation supports that the colpopexy was distinct and medically necessary.

CPT Code 57415 Coding and Billing Guidelines

CPT 57415 includes all necessary laparoscopic dissection, suspension, and fixation steps. Use of mesh is considered part of the primary procedure and not separately billable unless payer policy specifically allows it.

The procedure carries a 90-day global period per the 2025 Medicare Physician Fee Schedule. Postoperative care within that period is included.

If the colpopexy is performed with another major procedure (such as laparoscopic hysterectomy or pelvic repair), review NCCI edits to determine whether both services can be billed. Append modifier 59 (or XS) only when documentation supports that the colpopexy is a distinct, separately identifiable procedure.

Most commercial payers and Medicare Advantage plans require prior authorization for prolapse surgeries, particularly those involving mesh implants.

Reimbursement Information Under CPT Code 57415

For 2025, Medicare and major commercial payers classify CPT 57415 as a major laparoscopic reconstructive gynecologic procedure. The reimbursement level reflects the technical difficulty and operative time associated with laparoscopic pelvic repair.

Reimbursement varies by payer, contract, and region. Because this procedure is usually performed in a hospital or ambulatory surgical center, facility, and professional fees apply. The multiple-surgery reduction rule applies if more than one major procedure is billed during the same session.

Modifiers For CPT Code 57415

Use appropriate modifiers to clarify the surgical circumstances:

• Modifier 59 (or XS): Distinct procedural service from another operation.
• Modifier 51: Multiple procedures during the same session.
• Modifier 54 / 55: Division of surgical and postoperative management.
• Modifier 52: Reduced or incomplete service.

Do not apply laterality modifiers; this procedure involves the vaginal apex, not a left/right site.

Documentation Requirements For CPT Code 57415

Accurate and detailed operative documentation is necessary to support medical necessity and coding compliance. Include the following elements in the operative report:

• Preoperative diagnosis of prolapse type and stage.
• Laparoscopic approach and instruments used.
• Identification of fixation point (sacrum, uterosacral ligament, etc.).
• Materials used (mesh or sutures).
• Step-by-step surgical description of dissection and suspension.
• Documentation of any concurrent procedures.
• Postoperative findings and follow-up plan.

Clear, concise documentation prevents claim denials and supports audit readiness.

Example Scenarios

Scenario 1

Post-hysterectomy vault prolapse treated with laparoscopic colpopexy using sutures to suspend the vaginal cuff to the sacrum. → Report CPT 57415.

Scenario 2

Laparoscopic hysterectomy followed by distinct apical suspension for documented vaginal vault descent. → Report hysterectomy code + 57415 with modifier 59.

Scenario 3

Vaginal suspension is performed through an open abdominal incision. → Report CPT 57280.

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