Wiki Please confirm LEEP code

[tag60]

This is the first time I've coded a LEEP procedure, and I want to make sure I'm choosing the correct code. I've researched and read the CPT code descriptions carefully but just need confirmation of 57460/57461 or 57522. Note as follows:

Pt consented for LEEP/EMB. Prepped with Lugol's. Two passes with 10x15 LEEP. Then top hat done, single tooth tenaculum. Dilated with small dilator. Sounded to 5cm. EMB pipelle passed. Minimal tissue obtained. Tenaculum removed. Fulgurated circumferentially. Monsel's applied. Tolerated well. Pathology pending.

("top hat" refers to a deep second pass to obtain endocervical margin)


I believe this is 57522, biopsy obtained, no colposcopy done. Agree?

And the surgical pathology code would be Level V, 88307 (cervix, conization), correct?

Thanks for taking a look at this!

 

[tracylc10]

Yes, the LEEP is 57522.

This does not code the EMB or dilation though. These procedures are not normally done together. You would need to ask your provider why the EMB was done. I was looking in Coding Companion for Ob/Gyn and I believe you could use code 58120 with modifier 59 for these.

Regarding the surgical pathology code, this is usually coded by the lab that is billing for the test. If that is the case, then yes it would be 88307. If the specimen is being transported to an outside lab, you would report 99000 for handling and conveyance.

I hope this helps.