(2023) Colposcopy CPT Code | Description, Guidelines, Reimbursement, Modifiers & Examples

Colposcopy CPT code lies in the category of female reproductive system CPT: vulva (CPT 56820 – CPT 56821), vagina (CPT 57420 – CPT 57421), and cervix uteri (CPT 57452, CPT 57454, CPT 57455, CPT 57456, CPT 57460, and CPT 57461).

Colposcopy CPT Code Description

The following are official CPT codes and descriptions for Colposcopy and related services:

CPT 56820
CPT 56821
CPT 57420
CPT 57421
CPT 57452
CPT 57454
CPT 57455
CPT 57456
CPT 57460
CPT 57461
CPT 57465
CPT 58110

CPT 56820

CPT 56820 reports for service when a Colposcopy of the vulva performs by the physician. Colposcopy performs to visualize the woman’s genitals using a scope. 

CPT 56821

CPT 56821 reports for service when a Colposcopy of the vulva performs by the physician with a biopsy. Colposcopy performs to visualize the woman’s genitals using a scope with the removal of tissue(biopsy).   

CPT 57420

CPT 57420 reports for service when a Colposcopy of the entire vagina performs by the physician with the cervix if present. Colposcopy performs to visualize the vagina and or cervix if present using a scope.  

CPT 57421

CPT 57421 reports for service when a Colposcopy of the entire vagina performs by the physician with the biopsy. Colposcopy performs to visualize the vagina and or cervix if present using a scope with the removal of tissue(biopsy).  

CPT 57452

CPT 57452 reports for service when a Colposcopy of the cervix performs, including the upper or adjacent vagina. Colposcopy performs to visualize the cervix and upper or adjacent vagina using a scope.  

CPT 57454

CPT 57454 reports for service when a Colposcopy of the cervix performs, including the upper or adjacent vagina. Colposcopy performs to visualize the upper or adjacent vagina, cervix, and endocervical curettage using a scope with the removal of tissue (biopsy).  

CPT 57455

CPT 57455 reports for service when a Colposcopy of the cervix performs, including the upper or adjacent vagina. Colposcopy performs to visualize the cervix with the biopsy of the cervix.  

CPT 57456

CPT 57456 reports for service when a Colposcopy of the cervix performs, including the upper or adjacent vagina. Colposcopy performs to visualize the cervix with endocervical curettage.  

CPT 57460

CPT 57460 reports for service when a Colposcopy of the cervix performs, including the upper or adjacent vagina. Colposcopy performs to visualize the cervix with loop electrode biopsy(s) of the cervix.  

CPT 57461

CPT 57461 reports for service when a Colposcopy of the cervix performs, including the upper or adjacent vagina. Colposcopy performs to visualize the cervix with loop electrode conization of the cervix.  

CPT 57465

 CPT 57465 reports for service when a Colposcopy of the cervix performs, including the upper or adjacent vagina. It furnishes via Computer-aided mapping of cervix uteri which includes optical dynamic spectral imaging and algorithmic quantification of the Aceto-whitening effect.

CPT 57465 is an add-on code and reports in addition to CPT codes (57420-57421, 57452-57461).  

CPT 58110

CPT 58110 reports for service when a Colposcopy of the cervix performs, including the upper or adjacent vagina, with Endometrial sampling (biopsy).

CPT 58110 is an add-on code and reports in addition to CPT codes (57420-57421, 57452-57461).

Colposcopy CPT Code Description & Billing Guidelines

During this surgery, the provider uses a colposcope to examine the cervix, including the upper/adjacent area of the vagina. And the provider performs cervix biopsy(s) and tissue collection from the endocervical canal.

When performed as a “scout” technique to confirm a lesion or check the surgical field before a surgical procedure, Colposcopy CPT code (CPT codes 56820, 57420, 57452) is not reportable separately.

The coder can bill a diagnostic colposcopy separately by adding modifier 58 to the code for the non-colposcopy method.

Colposcopies are not reportable individually from other colposcopy operations (CPT codes 56820, 57420, and 57452) for diagnostic purposes.

CPT 56820 describes the colposcopy of the vulva, while CPT 56821 describes the colposcopy of the vulva; with biopsy(s).

The physician performs a colposcopy of the vulva, and the female’s external genitalia region, including the labia, clitoris, mons pubis, vaginal vestibule, bulb and glands, and vaginal orifice.

First, the patient positions herself in a lithotomy position.

Then, the physician examines the vulva with the help of a colposcope, a binocular microscope that allows for direct visualization of the vagina and cervix.

The colposcope’s powerful light examines the vulva and perianal area for lesions or ulcers.

Next, the provider obtains a biopsy of any vulvar tissue under direct eyesight (CPT 56821). The lesions determine the quantity and size of biopsy samples.

Finally, the provider puts pressure on the biopsy site and achieves hemostasis.

CPT 57420 defines a colposcopy of the entire vagina, with cervix if present. In contrast, CPT 57421 defines a colposcopy of the whole vagina with cervix if present and with biopsy(s) of the vagina/cervix.

The coder must also code CPT 57465 (computer-aided cervical mapping during colposcopy).

And he may use CPT 58110 (endometrial sampling or biopsy performed simultaneously with colposcopy) while coding CPT 57420 – CPT 57421.

In addition, he may use modifier 51 for Colposcopy CPT code procedures for different sites.

CPT 57452 defines a colposcopy of the cervix, including the upper/adjacent vagina.

Code also computer-aided cervical mapping, i.e., CPT 57465 with CPT 57452. The physician uses a colposcope to study the cervix and adjacent region of the vagina.

And he uses a binocular microscope to directly view the vagina, ectocervix, and endocervix. When a patient’s Pap test is abnormal, the physician performs this operation frequently.

The physician uses vinegar, iodine, or another solution to swab the vaginal walls and cervix to remove mucus and highlight abnormal cells by turning them white, making them more easily visible for biopsy. It may cause a tingling or burning feeling.

CPT 57454 Colposcopy CPT code of the cervix, including the adjacent vagina. And the physician takes biopsies of the cervix and endocervical curettage.

CPT 57455 narrates as a colposcopy of the cervix, including the adjacent vagina, and with biopsy of the cervix only.

CPT 57456 narrates a colposcopy of the cervix, including the adjacent vagina. And the physician takes a biopsy of endocervical curettage only.

To carry out the procedure (CPT 57454, CPT 57455, or CPT 57456), the physician inserts a scrapping instrument into the vaginal channel to thoroughly expose and check the cervix for atypical compartments.

Next, he uses a colposcope to examine the adjacent region of the vagina.

Next, he uses an optical microscope is to directly see the structures of the vagina, ectocervix, and endo-cervix.

Next, he removes mucus with the help of a specific solution and highlights atypical cells by coloring them, making them easier to identify for biopsy.

Finally, the cervix is biopsied by introducing a tool into the vaginal canal and extracting one or more tiny tissue samples.

CPT 57456 shows the physician conducts an endo-cervical curettage by inserting a tiny curette into the endo-cervical canal, the channel between the uterine cavity & external cervical.

Then, by scraping the trench with the curette, collect a specimen.

For CPT, the physician performs biopsies with endocervical curettage procedures in CPT 57454.

CPT 57452, CPT 57454, CPT 57455, and CPT 57456 are reportable also with computer-aided cervical mapping (CPT 57465) during colposcopy.

The coder must report each CPT code in a separate line item accompanied by primary CPT.

Computer-aided mapping of cervix uteri during service includes visual dynamic spectral imaging and algorithmic quantification of the aceto-whitening effect.

Colposcopy CPT code 57460 describes a colposcopy of the cervix, including the upper or adjacent vagina, and exclusively with loop electrode biopsy of the cervix. Code also computer-aided cervical mapping during colposcopy (57465).

As per the description, they (CPT 57460 and CPT 57461) include the introduction of a spoon-shaped instrument in the vagina for a thorough investigation of the cervix for irregular cells.

The physician also examines the vagina, ectocervix, and endocervix with the help of a microscope.

Next, he swabs the vaginal walls and cervix with vinegar or acetic acid to remove secretions and highlights the aberrant cells by turning them white, making them more easily visible for biopsy.

Sometimes, he performs a Schiller test in which he uses an iodine solution to cover the cervix.

The response may cause a minor tingling or burning feeling. For numbness of the region, he may use a local anesthetic.

Finally, he operates the loop electrode excision process to remove a biopsy specimen of cervical tissue (LEEP).

LEEP employs a small wire loop containing an electrical cutting current that functions as a cutting instrument to eliminate aberrant cells.

A grounding pad is connected to the patient’s leg during the operation due to the electrical current.

Monsel’s solution, a unique form of a paste that helps seal blood vessels and reduce bleeding, may be applied by the surgeon.

CPT 57461 describes a colposcopy of the cervix, including the vagina. And it includes loop electrode conization of the cervix.

All cervical colposcopy codes (57452-57461) include an inspection of the complete transformation zone and an examination of the vagina. The cervix is the critical focus of the colposcopy.

Colposcopy CPT code 57460 consists of the colposcopy and a loop electrode biopsy of the cervix. It is a method to retrieve a large tissue specimen(s) from the exocervix.

Regardless of the number of samples acquired, code 57460 is only recordable once. It does not entail the removal of a section of the transformation zone.

But the loop excision indicated by this code is not conization. The coder can use CPT 57461 when the physician conducts a loop electrode conization and a colposcopic exam.

The coder makes sure also to code CPT 57465 for computer-aided cervical mapping during colposcopy.

Colposcopy CPT code 56820 denotes colposcopy of the vulva and is reportable; it represents a different anatomic location.

The modifier 51 suggests that several operations were conducted on the same day by the same physician.

Colposcopy CPT Code Reimbursement and Modifiers

Reimbursement of colposcopy procedures depends significantly on the appropriate CPT and modifiers.

Insurance companies demand documentation for colposcopy procedures to prove that the services are legit If the physician performed services multiple times.

The colposcopy procedures have close resemblances, and a few of them have mutually exclusive edits (MUE). The coder must go through the MUE for colposcopy service performed.

CPT 57452: The fee for service (FFS) schedule for a non-facility is $132.09, and FFS for a facility is $99.89.

CPT 57454: FFS schedule for non-facility is $179.41, and for a facility is $146.82.

CPT 57455: FFS schedule for a non-facility is $169.91, and the FFS schedule for a facility is $120.24.

CPT 57456: FFS schedule for a non-facility is $159.79, and for a facility is $111.31.

CPT 57460: FFS schedule for a non-facility is $339.66, and for a facility is $175.92.

CPT 57461: The fee for service for a non-facility is $380.10, and the FFS schedule for a facility is $202.85.

The claim must support the medical necessity. A specific state governs local coverage determination (LCD), and as per reimbursement policy by Medicare, the ICD – 10 CM must be clear for each procedure.

Medicare may deny the claim containing unspecified diagnosis codes. Some of the commercial payers also follow Medicare policies.

The following are modifiers commonly used with colposcopy procedures:

Utilize modifier 22 when the technique takes longer than regular procedural services.  

Utilize Modifier 51 when the physician performs multiple operations at a time.

Utilize modifier 52 when the provider partially reduces the services because of uncertain circumstances.

Utilize modifier 53 when the physician discontinues a surgical or diagnostic procedure after starting the process due to some circumstance.

Utilize modifier 58 when the physician performs this procedure during the global period. It may be a related service by the same physician or other qualified health care professional during the postoperative period.

Utilize modifier 59 when the physician executes other distinct procedural services besides evaluation and management (E/M).

Utilize modifier 78 when a patient has an unanticipated return to the operative room. In this case, the qualified health care professional is the same and follows the initial procedure for a related process during the postoperative period.

Utilize modifier 79 when the physician performed an unrelated procedure by the same qualified healthcare professional during the postoperative period.

Example

The 47 years old female patient visited a physician for screening purposes.

First, the physician examines the cervix and vagina closely with the help of a spoon-shaped instrument.

The physician also biopsied the cervix for any abnormality and used a microscope for a close inspection.

In this case, the coder selected the Colposcopy CPT code 57455, including the colposcopy and biopsy of the cervix.

He may also use computer-aided cervical mapping CPT, i.e., 57465.