Ob-Gyn Coding Alert

Question: How should I report an endocervical biopsy?

Missouri Subscriber

Answer: Generally, you would use 57500 (Biopsy, single or multiple, or local excision of lesion, with or without fulguration [separate procedure]) if the ob-gyn performs the endocervical biopsy without a colposcopy. And you would report 57455 (Colposcopy of the cervix including upper/adjacent vagina; with biopsy[s] of the cervix) if he uses a colposcope for the biopsy.
 
The cervix has three parts: the exocervix (the outside part at the opening), the transformation zone (just inside the opening), and the endocervix (just past the transformation zone and stopping at the opening of the uterus). If the ob-gyn biopsied any of these areas, you would bill 57500 or 57455.
 
On the other hand, endocervical curettage (57456, ... with endocervical curettage; or 57505, Endocervical curettage [not done as part of a dilation and curettage]) involves scraping the lining of the endocervix to send cells to the lab for testing. This is not a biopsy from a coding perspective, even though the sample goes to pathology for a diagnosis. To determine which procedure the physician performed, closely examine the operative report.