Outpatient Facility Coding Alert

Question: Our physician documented the following report: “I brought in the colposcope and articulated with CO2 laser. There was initial laser border burned around the transformation zone. I maintained at 5 mm. Then I used the laser down to the cone of the cervix until I removed the specimen. I performed a cone biopsy at the cervix and tagged it with suture for marking. Then I brought the laser to the vulva. I noted small areas of condyloma to the left and right of the vaginal opening. Then I placed the laser back on the vulvar condyloma and ablated to the proper depth.” How should we report this?

Arizona Subscriber

Answer: To code this procedure correctly, you need to first look at the pathology report. Make sure part of the endocervix is in the sample (which makes this a conization of the cervix). Also, you should know if the doctor used a colposcope. Your doctor clearly states he did in the note.

With this in mind, you will report 57520 (Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; cold knife or laser) if the sample includes all or part of the endocervix. Even though you confirmed he used a colposcope for the procedure, you won’t find any code that includes it using this method for removal.

If your doctor did not take any of the endocervix, then you should report 57455 (Colposcopy of the cervix including upper/adjacent vagina; with biopsy[s] of the cervix) instead of 57520 and 57452 (Colposcopy of the cervix including upper/adjacent vagina) .

And of course, you may also bill separately for the destruction of the vulvar condyloma by reporting either 56501 (Destruction of lesion[s], vulva; simple [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery]) or 56515 (... extensive…).

Watch out: You should not report 57461 (Colposcopy of the cervix including upper/adjacent vagina; with loop electrode conization of the cervix). This code describes a conization done with a loop electrode (which your physician did not use).