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The procedure described by CPT® Code 57421 involves a colposcopy of the entire vagina, and if the cervix is present, it includes the cervix as well. A colposcopy is a diagnostic procedure that utilizes a specialized instrument known as a colposcope, which resembles a pair of binoculars mounted on a stand and equipped with a light source. This instrument is designed to magnify the tissues of the vagina and cervix, facilitating a detailed examination for any abnormalities. During the procedure, the colposcope is positioned at the vaginal opening, and a speculum is inserted into the vagina to gently separate the vaginal walls, allowing for a comprehensive inspection of the vaginal canal. The physician rotates the speculum to ensure that the entire vaginal wall is thoroughly examined. If the cervix is intact, the speculum is adjusted to provide a clear view of the cervix as well. The examination is conducted under varying magnifications, typically two or three, to enhance the visualization of any abnormal tissue. To further aid in identifying abnormal cells, acetic acid is applied to the tissues, which helps to highlight any irregularities. Following this, different-colored filters may be utilized to observe blood vessels and any atypical patterns that may indicate pathology. Additionally, an iodine solution is applied to stain the glycogen present in the cells; normal cells will exhibit a dark-brown coloration, while areas that do not stain are indicative of potential abnormalities and are targeted for biopsy. This procedure is critical for diagnosing conditions affecting the vagina and cervix, and it is important to note that CPT® Code 57421 is specifically used when one or more biopsies are performed during the colposcopy, distinguishing it from CPT® Code 57420, which is used for colposcopy without biopsy.
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The colposcopy procedure described by CPT® Code 57421 is indicated for various clinical scenarios where there is a need to investigate abnormalities in the vagina and cervix. The following conditions may warrant this procedure:
The procedure for CPT® Code 57421 involves several detailed steps to ensure a thorough examination of the vagina and cervix. The following outlines the procedural steps:
After the completion of the colposcopy and any biopsies, the patient may experience some mild discomfort or spotting. It is important for the physician to provide post-procedure care instructions, which may include avoiding sexual intercourse, tampons, and douching for a specified period to allow for healing. The patient should be informed about potential symptoms to watch for, such as heavy bleeding or signs of infection, and advised to follow up for biopsy results and further management as necessary. The physician will typically schedule a follow-up appointment to discuss the findings and any required next steps based on the biopsy results.
| Short Descr | EXAM/BIOPSY OF VAG W/SCOPE | Medium Descr | COLPOSCOPY ENTIRE VAGINA W/VAGINA/CERVIX BX | Long Descr | Colposcopy of the entire vagina, with cervix if present; with biopsy(s) of vagina/cervix | Status Code | Active Code | Global Days | 000 - Endoscopic or Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Procedure or Service, Multiple Reduction Applies | ASC Payment Indicator | Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on MPFS nonfacility PE RVUs. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 130 - Other diagnostic procedures, female organs |
This is a primary code that can be used with these additional add-on codes.
| 57465 | Female Edit Add-on Code MPFS Status: Active Code APC N Computer-aided mapping of cervix uteri during colposcopy, including optical dynamic spectral imaging and algorithmic quantification of the acetowhitening effect (List separately in addition to code for primary procedure) | 58110 | Female Edit Addon Code MPFS Status: Active Code APC N ASC N1 CPT Assistant Article Illustration for Code Endometrial sampling (biopsy) performed in conjunction with colposcopy (List separately in addition to code for primary procedure) |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 53 | Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | CR | Catastrophe/disaster related | FS | Split (or shared) evaluation and management visit | GA | Waiver of liability statement issued as required by payer policy, individual case | GC | This service has been performed in part by a resident under the direction of a teaching physician | KX | Requirements specified in the medical policy have been met | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | UA | Medicaid level of care 10, as defined by each state | X4 | Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2021-01-01 | Note | Guidelines changed. |
| 2006-01-01 | Changed | Code description changed. |
| 2003-01-01 | Added | First appearance in code book in 2003. |
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