Ob-Gyn Coding Alert

Question: My ob-gyn performed a LEEP of cervix as an outpatient procedure. Should I code this as 57522, or should I request the notes to see if the ob-gyn did something more extensive?

Washington Subscriber

Answer: You need to look at your ob-gyn's notes. A LEEP of the cervix can be a LEEP biopsy or a LEEP conization.

You should have documentation showing that the ob-gyn removed all of the exocervix, all of the transformation zone, and all or part of the endocervix to call it a conization. For a LEEP conization, you should report 57522 (Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; loop electrode excision). The procedure includes an ECC and D&C if performed so nothing more would be billed.

Code 57500 (Biopsy of cervix, single or multiple, or local excision of lesion, with or without fulguration [separate procedure]) is simply a biopsy of the cervix by any method. You would report this code if the physician performed a LEEP biopsy without colposcopy.