Ob-Gyn Coding Alert

Gynecology:

Do You Know How to Report What Ob-Gyn Did in Addition to Colposcope?

Published on Mon Dec 11, 2023

Tip: The difference between a biopsy and LEEP biopsy is the instrument used.

Your colposcopy coding choices are numerous, and so are the chances of picking the wrong code, which could cause you major headaches. What is vital is capturing what your ob-gyn did in addition to the colposcope — biopsy, endocervical curettage, or loop electrocautery excision procedure (LEEP).

These three colposcopy scenarios will uncover any issues you may have. Choose the proper CPT^® code and ICD-10 code in each case, and see how you fare.

Scenario 1: Highlight 3 Key Phrases in This Note

“I noted an abnormality consisting of atypical vessels during the exam. At 12 o’clock, the patient had abnormal acetowhite areas extending into the endocervical canal, and I took a cervical biopsy. I treated the biopsy site with Monsel’s solution for hemostasis.”

What CPT^® and ICD-10 codes should you report in this situation?

Solution: First, you should isolate the important information. The critical phrases are:

Including upper/adjacent vagina
Transformation zone completely
Cervical biopsy at 12 o’clock

CPT®: Narrow down your coding options. From the first phrase, you know to look at the codes that describe the inspection of the cervix with upper/adjacent vagina.

Therefore, your options are 57454 (Colposcopy of the cervix including upper/adjacent vagina; with biopsy[s] of the cervix and endocervical curettage), 57455 (... with biopsy[s] of the cervix), 57456 (... with endocervical curettage), 57460 (… with loop electrode biopsy(s) of the cervix), or 57461 (…with loop electrode conization of the cervix). Your decision depends on the additional procedure the ob-gyn does, whether it is a biopsy, endocervical curettage (ECC), LEEP excision, and so on.

In this case, the ob-gyn performed only a biopsy, hence the third phrase: “cervical biopsy at 12 o’clock.” You will report 57455 for this procedure.

Note: The difference between a biopsy and a LEEP biopsy is the instrument used. Either method will take a sample of tissue from the cervix but does not remove the entire section of the cervix in question.

ICD-10: Although you need more information to choose your ICD-10 appropriately (because you must always base it on the physician’s documentation), you will have to wait until the biopsy result comes back. If you are coding prior to knowing this information, you would report the reason for the colposcopic exam, such as R87.61- (Abnormal cytological findings in specimens from cervix uteri). The codes for cervical dysplasia include N87.0, N87.1, and D06.0 or D06.1 (depending on whether the path report indicates ca in situ of the endo or exocervix).

Scenario 2: Keep Similarities With First Procedure in Mind

Procedure: Your ob-gyn’s documentation states: “I cleansed the cervix, including upper/adjacent vagina, several times with 3 percent acetic acid. After adequate time for the acetic acid effect, I examined the cervix and vaginal fornices with a colposcope at several magnifications. I looked at the transformation zone completely. I noted abnormal acetowhite areas at 12 o’clock, extending into the endocervical canal. Finally, I performed an endocervical curettage and cervical biopsy. I treated the biopsy site with silver nitrate for hemostasis.”

What CPT^® and ICD-10 codes should you report in this situation?

Solution: Again, you should isolate the key phrases:

Including upper/adjacent vagina
Transformation zone completely
An endocervical curettage and cervical biopsy.

CPT^®: The phrase “including upper/adjacent vagina” tells you what colposcope codes to look for. Because the ob-gyn performed an endocervical curettage and cervical biopsy in addition to the colposcope, you should report 57454.

ICD-10: Again, although you need more information to choose the ICD-10 code appropriately (because you must always base it on your physician’s documentation), the likely codes are R87.61- (Abnormal cytological findings in specimens from cervix uteri) or the N87.- or D06.- codes should the path report indicate dysplasia.

Scenario 3: Prepare for LEEP to Enter the Picture

“I infiltrated the cervix from 11 to 12 o’clock. with lidocaine. I used an appropriate-sized loop electrode to ensure excision of the lesion on the ectocervix with adequate margins. I used a second loop to remove the involved portion of the endocervix. At the conclusion of the excision, I used a curette to sample the upper boundary of the excision to ensure complete removal of the dysplasia. I achieved hemostasis with electrocautery and topical Monsel’s solution.”

What CPT^® and ICD-10 codes should you report in this situation?

Solution 3: The key phrases are:

Including upper/adjacent vagina
Determined the size of the lesion
Excision of the lesion on the ectocervix with adequate margins
Used a second loop to remove the involved portion of the endocervix
At the conclusion of the excision, I used a curette.

CPT^®: These phrases direct you to use 57461. This code includes a LEEP conization, which is appropriate because the ob-gyn removed part of the endocervix rather than just performing a biopsy of the cervix. The use of the curette at the end of the procedure is included in any conization procedure.

ICD-10: Again, although you need more information to choose the ICD-10 code appropriately (because you must always base it on what is on the patient report), probable codes include N87.0, N87.1, D06.0 or D06.1 (CIN I, II or III respectively) for the cervical dysplasia codes since the procedure report specifically mentions dysplasia and a conization is done to treat the existing dysplasia, not to diagnose a problem.