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The procedure described by CPT® Code 57461 involves a comprehensive examination and treatment of the cervix and upper adjacent vagina through colposcopy, combined with a loop electrode conization of the cervix. Colposcopy is a diagnostic procedure that utilizes a specialized instrument known as a colposcope, which resembles binoculars mounted on a stand and is equipped with a light source. This instrument magnifies the cervical and vaginal tissues, enabling the physician to identify any abnormal areas that may require further investigation or intervention. During the procedure, the physician first inserts a speculum 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, iodine solution is used to stain the cells, allowing for differentiation between normal and abnormal tissues based on their staining characteristics. Areas that do not take up the iodine stain, along with those previously identified as abnormal, are targeted for biopsy using a loop electrode. This technique, known as loop electrical excision procedure (LEEP), involves the use of a thin wire loop that conducts an electrical current to excise tissue samples. In addition to diagnostic purposes, this procedure also includes conization, which is the surgical removal of a cone-shaped section of cervical tissue. This is performed to excise the entire transformation zone, which is critical for identifying and treating precancerous lesions. The conization can be achieved in a single pass or through a two-pass technique, depending on the extent of the tissue that needs to be removed. To manage any bleeding that may occur during the procedure, the cervix is treated with Monsel solution or electrocautery, ensuring patient safety and minimizing complications.
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The procedure described by CPT® Code 57461 is indicated for the following conditions:
The procedure begins with the physician positioning the patient appropriately and inserting a speculum into the vagina to allow for a clear view of the cervix and upper adjacent vaginal wall. The colposcope is then placed at the vaginal opening, providing magnified visualization of the cervical and vaginal tissues. The physician examines these areas under two or three different magnifications to identify any abnormal tissue. Following the initial examination, acetic acid is applied to the cervix, which enhances the visibility of abnormal cells by causing them to appear white. After the application of acetic acid, the physician uses different-colored filters to assess blood vessels and any abnormal patterns that may indicate pathology. Subsequently, an iodine solution is applied to stain the cervical cells, where normal cells will take on a dark-brown color due to the presence of glycogen. Areas that do not stain, along with those previously identified as abnormal, are marked for biopsy. For the biopsy, a thin wire loop that conducts an electrical current is utilized to excise the targeted tissue samples. This technique, known as loop electrical excision procedure (LEEP), allows for precise removal of abnormal tissue. The patient is placed on a grounding pad, and an insulated speculum connected to smoke-evacuator tubing is inserted into the vagina to manage any smoke produced during the procedure. A local anesthetic with epinephrine is injected beneath the surface of the cervical epithelium to minimize discomfort during the excision. The conization of the cervix is then performed, which involves the removal of a cone-shaped section of cervical tissue. This is achieved using the thin wire loop to ensure complete excision of the transformation zone, which may be done in a single pass or through a two-pass technique, depending on the extent of tissue removal required. To control any bleeding that may occur during the procedure, the cervix is treated with Monsel solution or electrocautery, ensuring effective hemostasis.
After the completion of the procedure, patients are typically monitored for any immediate complications, such as excessive bleeding or signs of infection. It is common for patients to experience some cramping or spotting following the procedure, which is generally considered normal. Patients may be advised to avoid sexual intercourse, douching, or using tampons for a specified period to allow for proper healing of the cervix. Follow-up appointments are often scheduled to review biopsy results and to determine if any further treatment is necessary based on the findings. Additionally, patients should be informed about signs of complications that warrant immediate medical attention, such as heavy bleeding or fever.
| Short Descr | CONZ OF CERVIX W/SCOPE LEEP | Medium Descr | COLPOSCOPY CERVIX VAG ELTRD CONIZATION CERVIX | Long Descr | Colposcopy of the cervix including upper/adjacent vagina; with loop electrode conization 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) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 125 - Other excision of cervix and uterus |
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). | 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. | 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 | 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 | 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. |
| 2011-01-01 | Changed | Short description changed. Guideline information changed. |
| 2003-01-01 | Added | First appearance in code book in 2003. |
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