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The procedure described by CPT® Code 57460 involves a colposcopy of the cervix and the upper adjacent vagina, accompanied by loop electrode biopsy(s) of the cervix. 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 magnifies the tissues of the cervix and vagina, enabling the physician to identify any abnormal areas that may require further investigation. During the procedure, a speculum is inserted into the vagina to facilitate a clear view of the cervix and upper adjacent vaginal wall. The examination is conducted under varying magnifications to enhance the visualization of the tissues. To improve the detection of abnormal cells, acetic acid is applied to the cervix, which highlights areas of dysplasia or other abnormalities. Following this, colored filters are utilized to observe blood vessels and any atypical patterns that may indicate pathology. An iodine solution is then applied to stain the cells, with normal cells appearing dark brown, while abnormal areas remain unstained and are subsequently biopsied. The biopsy is performed using a thin wire loop that conducts an electrical current, a technique commonly referred to as a loop electrical excision procedure (LEEP). This method allows for the precise removal of tissue samples for further pathological examination. The procedure may also involve the use of a local anesthetic to minimize discomfort during the biopsy process. Overall, CPT® Code 57460 encapsulates a comprehensive approach to diagnosing and managing cervical abnormalities through advanced visualization and targeted tissue sampling.
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The procedure described by CPT® Code 57460 is indicated for the evaluation and management of various cervical abnormalities. The following conditions may warrant the performance of this procedure:
The procedure for CPT® Code 57460 involves several detailed steps to ensure accurate diagnosis and treatment. The following outlines the procedural steps:
After the completion of the colposcopy and biopsy, the patient may experience some mild discomfort or spotting. It is important for the patient to be monitored for any excessive bleeding or signs of infection. Patients are typically advised to avoid sexual intercourse, douching, or using tampons for a specified period following the procedure to promote healing. Follow-up appointments may be scheduled to discuss biopsy results and any further management that may be necessary based on the findings.
| Short Descr | BX OF CERVIX W/SCOPE LEEP | Medium Descr | COLPOSCOPY CERVIX VAG LOOP ELTRD BX CERVIX | Long Descr | Colposcopy of the cervix including upper/adjacent vagina; with loop electrode 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 | Hospital Part B services paid through a comprehensive APC | 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) |
| 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). | 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). | 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.) | AG | Primary physician | 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 | CG | Policy criteria applied | 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 | 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 | SG | Ambulatory surgical center (asc) facility service | UA | Medicaid level of care 10, as defined by each state | 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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| 2011-01-01 | Changed | Short description changed. |
| 2003-01-01 | Changed | Code description changed. |
| 1993-01-01 | Added | First appearance in code book in 1993. |
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