Wiki Leep procedure

[amph0803]

I’m new to obgyn coding and wanted some confirmation for my cpt code. Would the following procedure be cpt code 57460? How do I know when it’s a conization?

Procedure note- pt was placed in the semi-Fowler lithotomy position. Pt external female genitalia appeared within normal limits. A speculum was inserted. The vaginal epithelium was visualized and appeared to be within normal limits. Her cervix is easily visualized. A colposcope was used to further visualize her cervix and the lesion. Lugol solution was placed on her cervix, and the entire extent of the lesion was identified. The patient's cervical stroma was injected with 1% lidocaine superficially circumferentially around her cervix. A small loop was used to perform the LEEP in two passes. The specimen was labeled, submitted to Pathology, and electrocutery and Monsel solution was applied.

 

[Cmama12]

Hi, this documentation is not great. Both 57460 and 57461 should include the exocervix and transformation zone; a conization also includes the endocervix. Here's an an example note

The patient was placed in the exam chair in the dorsal lithotomy position. A grounding pad was applied. External genitalia appeared normal. A coated speculum was inserted and the cervix visualized in its entirety. No vaginal lesions were seen. The cervix was cleaned with a cotton-tipped swab. Acetic acid solution was then applied and colposcopy again performed. Findings include acetowhite change similar to her colposcopy, 12:00 and 6:00. The cervix was then coated with Lugol solution and paracervical block performed at the 4, 8, and 12:00 positions. An appropriate electrosurgical loop device was selected and the ectocervix surrounding the transformation zone was excised, the transformation zone was close to the cervical os so this was able to be taken in one pass. An endocervical specimen was also obtained. Hemostasis was then obtained using ball electrocautery and Monsel solution applied. All instruments were removed. The patient had tolerated the procedure well and was stable following.


Leep conization 57461 includes endocervical speciman