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The procedure described by CPT® Code 57454 involves a comprehensive examination of the cervix and the upper adjacent vagina through a technique known as colposcopy. This procedure utilizes a specialized instrument called a colposcope, which resembles a pair of binoculars mounted on a stand and equipped with a light source. The primary purpose of the colposcope is to magnify the tissues of the cervix and upper adjacent vagina, thereby enhancing the physician's ability to identify any abnormal tissue or lesions that may be present. 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 clear view of the cervix and the upper adjacent vaginal wall. The examination is conducted under varying magnifications—typically two or three—to facilitate a thorough assessment of the cervical and vaginal tissues. To improve the visualization of abnormal cells, acetic acid is applied to the area, which helps to highlight any irregularities. Following this, different-colored filters may be employed to observe blood vessels and any unusual patterns that may indicate pathology. Additionally, an iodine solution is applied to stain the cells, with normal cells exhibiting a dark-brown color due to the presence of glycogen. Areas that do not take up the stain, as well as those previously identified with abnormal blood vessel patterns, are targeted for biopsy. Furthermore, an endocervical curettage (ECC) may be performed if necessary, which involves scraping the cervical canal with a curet to collect tissue samples for further analysis. This procedure is critical for diagnosing conditions such as cervical dysplasia or cancer, and it is essential for ensuring appropriate follow-up and treatment.
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The procedure described by CPT® Code 57454 is indicated for the following conditions:
The procedure begins with the patient positioned appropriately for a gynecological examination. The physician first inserts a speculum into the vagina to allow access and visibility of the cervix and upper adjacent vagina. Once the speculum is in place, the colposcope is positioned at the vaginal opening, providing a magnified view of the cervical area. The physician examines the cervix and upper adjacent vagina under two or three different magnifications to identify any abnormal areas. To enhance visualization, acetic acid is applied to the cervix, which helps to highlight abnormal cells by causing them to appear whiter. Following this, the physician may use different-colored filters to observe the blood vessels in the area, looking for any abnormal patterns that could indicate pathology. After the application of acetic acid, an iodine solution is painted onto the cervix and upper adjacent vagina. Normal cells will stain a dark-brown color due to the presence of glycogen, while areas that do not stain are noted for biopsy. The physician will then proceed to biopsy these areas, as well as any previously identified abnormal blood vessel patterns. This involves taking small tissue samples from the cervix for further pathological examination. If deemed necessary, an endocervical curettage (ECC) is performed, which involves scraping the cervical canal with a curet to collect additional tissue samples. This step is crucial for obtaining deeper samples from the cervical canal, which may reveal further abnormalities not visible on the surface. The entire procedure is conducted with care to ensure patient comfort and safety while obtaining the necessary diagnostic information.
After the completion of the colposcopy with biopsy and endocervical curettage, patients may experience some mild discomfort, cramping, or light bleeding, which is generally expected. It is important for patients to be informed about these potential post-procedure symptoms. They should be advised to avoid using tampons, douching, or engaging in sexual intercourse for a specified period, typically 48 hours, to allow for proper healing and to minimize the risk of infection. Patients will also be instructed to monitor for any signs of excessive bleeding, severe pain, or unusual discharge, and to contact their healthcare provider if these symptoms occur. Follow-up appointments may be scheduled to discuss biopsy results and any further necessary treatment based on the findings. This post-procedure care is essential for ensuring patient safety and effective management of any identified conditions.
| Short Descr | BX/CURETT OF CERVIX W/SCOPE | Medium Descr | COLPOSCOPY CERVIX BX CERVIX & ENDOCRV CURRETAGE | Long Descr | Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix and endocervical curettage | Status Code | Active Code | Global Days | 000 - Endoscopic or Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 3 - Special payment adjustment rules for multiple endoscopic 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. | Endoscopic Base Code | 57452 Colposcopy of the cervix including upper/adjacent vagina; | 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) | P8I - Endoscopy - 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) |
| 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. | GC | This service has been performed in part by a resident under the direction of a teaching physician | 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). | UA | Medicaid level of care 10, as defined by each state | GA | Waiver of liability statement issued as required by payer policy, individual case | 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. | 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. | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 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.) | AG | Primary physician | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | 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 | GW | Service not related to the hospice patient's terminal condition | GY | Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit | GZ | Item or service expected to be denied as not reasonable and necessary | KX | Requirements specified in the medical policy have been met | PD | Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | SG | Ambulatory surgical center (asc) facility service | X1 | Continuous/broad services: for reporting services by clinicians, who provide the principal care for a patient, with no planned endpoint of the relationship; services in this category represent comprehensive care, dealing with the entire scope of patient problems, either directly or in a care coordination role; reporting clinician service examples include, but are not limited to: primary care, and clinicians providing comprehensive care to patients in addition to specialty care | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | 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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| 2013-01-01 | Changed | Medium Descriptor changed. |
| 2003-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
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