General Surgery Coding Alert

Question: Our surgeon performed a colposcopy and used a loop electrocautery excision of cervical tissue. How should I code this?

New Mexico Subscriber

Answer: You don’t provide quite enough information to narrow down the code selection. You’re describing a loop electrosurgical excision procedure (LEEP), but what you’ve stated would lead to one of the following codes:

• 57460 (Colposcopy of the cervix including upper/ adjacent vagina; with loop electrode biopsy(s) of the cervix)
• 57461 (… with loop electrode conization of the cervix)

You can see that the distinction between these two codes is whether the surgeon takes a biopsy or conization of the cervix. The surgeon should clearly state in the op report if this is a conization or biopsy.

Tip: If you don’t have that clear designation from your surgeon, some anatomic knowledge can help you choose the correct code in this case. Generally speaking, a LEEP biopsy samples only as high as the transformation zone, while a LEEP conization involves removing a tissue “cone” that takes the ectocervix, transformation zone, and goes up into the endocervix.