Ob-Gyn Coding Alert

Reporting 57460 and 57461 means having this in your documentation.

If you have a Loop Electrode Excision Procedure (LEEP) claim on your desk, then you need to ask, “Did he remove part of the endocervix?” Not sure what the endocervix is? Our experts break down the anatomy, terminology, and your choice of LEEP coding options into relatable terms.

Key: Remember, you need to know the difference between a LEEP biopsy of the cervix and the conization of the cervix lies in your ob-gyn’s documentation

Step 1: Get to Know Uterine/Cervical Anatomy

In order to understand the conization of the cervix, you need to have a clear concept of the uterus and cervix and the sections therein.

Get anatomical: The uterus and the cervix are not two different structures. The uterus is a muscular, pear-shaped organ with thick walls. The uterus has two portions:

The top portion is above what is called the internal os or the isthmus, and that is the body of the uterus.

The area below that internal os or isthmus is called the cervix. The cervix is sometimes referred to in the text and certainly in the CPT® book as the “cervix uteri,” because it belongs to the uterus, says Melanie Witt, RN, MA, an independent coding consultant in Guadalupita, N.M.

Focus on the cervix: The cervix has a several sections before it reaches that internal os. If you examine a diagram, you’ll see:

• an external opening, which opens directly into the vagina
• the transformation zone, which is above the "ecto- or exocervix" and inside the external os, Also, this is the place where the cervical cells change from squamous cells to columnar cells
• the "endocervix," above that transformation zone up to the internal os.

The endocervix is generally where physicians do an endocervical curettage (ECC), for instance. And during a Pap smear, an ob-gyn will take the sampling brush and go up into the endocervix, twirl it around and bring it back down, to ensure that the sample includes cells from the transformation zone.

Step 2: Take This Anatomy Knowledge and Apply Into LEEP Terms

When an ob-gyn performs a biopsy of the cervix, the procedure will generally stay in the lower half, but can go as high as the transformation zone. However, you have to pay particular attention to LEEP procedures.

When LEEP is a biopsy: When the ob-gyn performs a LEEP biopsy, a machine that has an electric loop goes into the transformation zone and pulls up tissue from that area. In other words, as long as the machine stays right at that transformation zone, you should consider this a biopsy.

When LEEP is conization: When the ob-gyn goes beyond the transformation zone and gets up into the endocervical canal, you’ll change to conization. The ob-gyn is taking a cone of the cervix out, and it has to include parts of the endocervix.

Keep in mind: Both cervical biopsy and ECC are integral parts of the LEEP conization, meaning you cannot bill for these services separately, Witt says.

Step 3: Now Examine What CPT® Codes You’ll Report

Your ob-gyn’s removal or lack of removal of the endocervix is vital to determining whether he performed a conization or a biopsy. Check out the codes specific to each type of LEEP service.

These are the conization codes:

Code 57522 (Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; loop electrode excision) describes a LEEP conization procedure. The ob-gyn takes all of the exocervix, all of the transformation zone, and all or part of the endocervix without using a colposcope. This code has 7.45 relative value units (RVUs) when the ob-gyn performs the procedure in the office.

Code 57461 (Colposcopy of the cervix including upper/adjacent vagina; with loop electrode conization of the cervix) describes a conization of the cervix using a colposcope. This code has 9.03 RVUs.

These are the biopsy codes:

Code 57460 (... with loop electrode biopsy[s] of the cervix) describes a LEEP cervical biopsy with the use of a colposcope. The ob-gyn takes the exocervix and all or part of the transformation zone but not the endocervix. This code has 7.99 RVUs.

Watch out: Both 57460 and 57461 require an examination of the entire cervix and the upper adjacent portion of the vagina. The ob-gyn should document this in his record. If the ob-gyn uses a colposcope only to guide the loop electrode, he will not have met the requirements for reporting 57460-57461. In this case, you should code a cervical biopsy using a loop electrode without a colposcope as:

• 57500 (Biopsy of cervix, single or multiple, or local excision of lesion, with or without fulguration [separate procedure]) or
• 57522 instead, as long as your ob-gyn performed an actual conization and documented it.

Got It? Now Tackle This Scenario

Scenario: Your ob-gyn performs a LEEP procedure in which he removes all of the exocervix, all of the transformation, and part of the endocervix. He performed an ECC as well as a cervical biopsy. He did not use a colposcope. What would you report?

Solution: You would report 57522 for the whole procedure.

Watch out: If the ob-gyn used a colposcope in this example, that doesn’t mean that you would report 57456 (Colposcopy of the cervix including upper/adjacent vagina; with endocervical curettage) as well because an ECC is always included in any conization procedure. Instead, your code would simply change to 57461.

Remember: A cervical biopsy is also an integral part of the LEEP conization. This means you cannot bill it separately because part of the specimen will be the cervix.