Ob-Gyn Coding Alert

We have received comments from several readers about the answer to the Reader Question in the October 2006 Ob-gyn Coding Alert titled -Leap to the Right LEEP Code Every Time.- The answer presented did not imply that a physician merely had to use a colposcope in performing either 57460 (Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy[s] of the cervix) or 57461 (... with loop electrode conization of the cervix). 

As we made clear in our December 2002 article announcing the addition of these codes to CPT, these codes require an examination of the entire cervix and the upper adjacent portion of the vagina, and the physician should document this in the record. 

If the ob-gyn uses the colposcope only to guide the loop electrode, you will not have met the requirements for reporting 57460 and 57461. If this is the case, you should report 57500 (Biopsy, single or multiple, or local excision of lesion, with or without fulguration [separate procedure]) or 57522 (Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; loop electrode excision) instead.