Ob-Gyn Coding Alert

Question: The physician noted that he performed laser vaporization of the ectocervix under colposcopic guidance using the inverted hat technique. Should I report this with 57461, or is there a better way?

Georgia Subscriber

Answer: This procedure is the same as laser ablation of the cervix. You should report it as 57513 (Cautery of cervix; laser ablation). Be sure to add a second code for the cervical colposcopy (57452*, Colposcopy of the cervix including upper/adjacent vagina) and append modifier -51 (Multiple procedures) to show that the ob-gyn performed more than one procedure during the session.

Code 57461 ( with loop electrode conization of the cervix) is for a top hat procedure, which involves removing all of the ectocervix, all of the transformation zone, and all or part of the endocervix with a loop electrode. Because the physician used a laser, 57461 would not be appropriate in this case.