How To Use CPT Code 57410

CPT 57410 refers to a pelvic examination performed under anesthesia other than local, and this article will cover its description, procedure, qualifying circumstances, usage, documentation requirements, billing guidelines, historical information, similar codes, and examples.

1. What is CPT 57410?

CPT 57410 is a medical code used to describe a pelvic examination performed under anesthesia other than local. This procedure is typically performed when a patient is unable to tolerate a standard pelvic examination due to pain or other factors, and requires anesthesia for the examination to be completed.

2. 57410 CPT code description

The official description of CPT code 57410 is: “Pelvic examination under anesthesia (other than local)”.

3. Procedure

1. The patient is placed in a dorsal lithotomy position.
2. Anesthesia other than local is administered to the patient.
3. The physician examines the external and internal genitalia.
4. A speculum is inserted to examine the cervix and vagina.
5. If indicated, a Pap smear specimen may be collected from the cervix or vaginal canal.
6. A bimanual examination of the pelvis is performed to identify any changes in organ size.

4. Qualifying circumstances

Patients eligible to receive CPT code 57410 services are those who require a pelvic examination but are unable to tolerate the procedure without anesthesia other than local. This may include patients with a history of severe pain during pelvic examinations, those with anxiety or fear related to the examination, or individuals with certain medical conditions that make a standard pelvic examination difficult or impossible to perform.

5. When to use CPT code 57410

It is appropriate to bill the 57410 CPT code when the pelvic examination is the only service provided and the patient requires anesthesia other than local to tolerate the procedure. If the examination is performed in an office setting and the physician uses moderate sedation or a local anesthetic, it is considered part of an E/M service and should not be billed separately.

6. Documentation requirements

To support a claim for CPT 57410, the following information should be documented:

• Medical necessity for the examination under anesthesia
• Type of anesthesia used
• Detailed description of the examination findings
• Any specimens collected during the procedure
• Results of the bimanual examination

7. Billing guidelines

When billing for CPT code 57410, it is important to follow the appropriate guidelines and rules. This code should only be billed when the pelvic examination under anesthesia is the sole service provided. If other procedures are performed during the same session, the examination may be bundled into those services and not billed separately. Additionally, if the examination is performed in an office setting with moderate sedation or local anesthetic, it should be considered part of an E/M service and not billed separately.

8. Historical information

CPT 57410 was added to the Current Procedural Terminology system on January 1, 1990. The code was changed on January 1, 2009, with the previous descriptor being “Pelvic examination under anesthesia”.

9. Similar codes to CPT 57410

Five similar codes to CPT 57410 and how they differ are:

1. CPT 57420: This code is for a diagnostic examination of the vagina and cervix under anesthesia, which is more focused on these specific areas than the broader pelvic examination in CPT 57410.
2. CPT 57421: This code is for a diagnostic examination of the vagina, cervix, and uterus under anesthesia, which includes the uterus in addition to the areas examined in CPT 57420.
3. CPT 57452: This code is for a colposcopy of the cervix, which is a more specialized examination using a colposcope to visualize the cervix and identify abnormal cells.
4. CPT 57454: This code is for a colposcopy of the cervix with biopsy, which includes the removal of tissue samples for further examination.
5. CPT 57455: This code is for a colposcopy of the cervix with loop electrode biopsy, which uses a loop electrode to remove tissue samples during the colposcopy.

10. Examples

1. A patient with a history of severe pain during pelvic examinations requires a routine examination and is unable to tolerate the procedure without anesthesia other than local. CPT 57410 would be billed for this service.
2. A patient with a history of sexual trauma experiences extreme anxiety during pelvic examinations and requires anesthesia other than local to complete the examination. CPT 57410 would be billed for this service.
3. A patient with a medical condition that causes involuntary muscle contractions in the pelvic area requires a pelvic examination and is unable to tolerate the procedure without anesthesia other than local. CPT 57410 would be billed for this service.
4. A patient with a suspected pelvic mass requires a pelvic examination under anesthesia other than local for a thorough evaluation. CPT 57410 would be billed for this service.
5. A patient with a history of severe endometriosis experiences significant pain during pelvic examinations and requires anesthesia other than local to complete the examination. CPT 57410 would be billed for this service.
6. A patient with a suspected cervical or vaginal infection requires a pelvic examination under anesthesia other than local to obtain specimens for testing. CPT 57410 would be billed for this service.
7. A patient with a history of pelvic inflammatory disease requires a pelvic examination under anesthesia other than local to evaluate for any changes in organ size. CPT 57410 would be billed for this service.
8. A patient with a suspected ectopic pregnancy requires a pelvic examination under anesthesia other than local for a thorough evaluation. CPT 57410 would be billed for this service.
9. A patient with a history of pelvic adhesions requires a pelvic examination under anesthesia other than local to evaluate for any changes in organ size or mobility. CPT 57410 would be billed for this service.
10. A patient with a suspected ovarian cyst requires a pelvic examination under anesthesia other than local for a thorough evaluation. CPT 57410 would be billed for this service.