february 2009

COLPOSCOPY FACTS

1. A colposcopy can be reported one time for each anatomical location examined. For example; if the physician performs a colposcopy of the vulva, and a colposcopy of the cervix with loop electrode conization procedure it would be appropriate to report the following CPT codes:

56820 – Colposcopy of the vulva

57461 – Colposcopy of the cervix including upper/adjacent vagina with loop electrode conization of the cervix

2. If a sampling of the endometrium is taken from the uterus during a colposcopy of the vagina or cervix then add-on code + 58110 – Endometrial sampling (biopsy) performed in conjunction with colposcopy may be additionally reported.

3. A conization procedure includes any fulguration, dilation and curettage, or repair so these services are not separately reported. For that reason you would not report 57456 – Colposcopy of the cervix with endocervical curettage and 57461 -Colposcopy of the cervix with loop electrode conization of the cervix during the same operative session.

4. In CPT code 57460 a portion of the exocervix is removed with a loop electrode as a biopsy procedure. Notice how the electrode is dragged across the cervix removing only the outer layer. Once this has been accomplished a second narrower loop can then be used to biopsy the deeper tissue within the transformation zone. With CPT code 57461 a cone shaped portion of the cervix is removed to include the transformation zone. The cervix has two types of cells called squamous and columnar. The area where these two cell types meet is called the squamocolumnar junction (transition zone) and this is the area where cervical cancer is most prone to development.