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The procedure described by CPT® Code 57455 involves a colposcopy of the cervix and the upper adjacent vagina, which is a diagnostic examination performed by a physician to assess the health of these areas. A colposcope, a specialized instrument resembling binoculars mounted on a stand with an integrated light source, is utilized to magnify the tissues of the cervix and upper adjacent vagina. This enhanced visualization is crucial for identifying any abnormal tissue that may require further investigation. 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, providing a clear view of the cervix and upper adjacent vaginal wall. The examination is conducted under varying magnifications, typically two or three, to ensure thorough assessment. To improve the visibility of abnormal cells, acetic acid is applied to the cervix and upper adjacent vagina. This application helps to highlight any areas of concern. Following this, different-colored filters are employed to visualize blood vessels and detect any abnormal patterns in blood vessel formation. Additionally, an iodine solution is applied to stain the cells, where normal cells will exhibit a dark-brown color due to the presence of glycogen. Areas that do not take up the iodine stain, as well as those previously identified with abnormal blood vessel patterns, are targeted for biopsy. If necessary, an endocervical curettage (ECC) may be performed, which involves scraping the cervical canal with a curet to collect tissue samples for further analysis. This comprehensive approach allows for accurate diagnosis and management of cervical and vaginal health issues.
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The colposcopy procedure described by CPT® Code 57455 is indicated for various clinical scenarios where there is a need for detailed examination of the cervix and upper adjacent vagina. The following conditions may warrant this procedure:
The procedure for CPT® Code 57455 involves several key steps to ensure a thorough examination and accurate diagnosis. The following outlines the procedural steps:
After the completion of the colposcopy and any biopsies or ECC performed, the patient may experience some mild discomfort or spotting. It is important for the patient to be informed about potential post-procedure symptoms, which can include light bleeding or cramping. Patients are typically advised to avoid sexual intercourse, douching, or using tampons for a specified period following the procedure to allow for proper healing. Follow-up appointments may be scheduled to discuss biopsy results and any further management required based on the findings. The physician will provide specific instructions regarding post-procedure care and any necessary follow-up actions.
| Short Descr | BIOPSY OF CERVIX W/SCOPE | Medium Descr | COLPOSCOPY CERVIX UPPR/ADJCNT VAGINA W/CERVIX BX | Long Descr | Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix | 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) | 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) |
| 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. | AG | Primary physician | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | CR | Catastrophe/disaster related | 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 | 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 | 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 | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| 2003-01-01 | Added | First appearance in code book in 2003. |
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