How To Use CPT Code 57454

CPT 57454 refers to a colposcopy of the cervix, including the upper/adjacent vagina, with biopsy(s) of the cervix and endocervical curettage. This article will cover the description, procedure, qualifying circumstances, when to use the code, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 57454 procedures.

1. What is CPT 57454?

CPT 57454 is a medical procedure code used to describe a colposcopy of the cervix, including the upper/adjacent vagina, with biopsy(s) of the cervix and endocervical curettage. This procedure is performed to examine the cervix and upper vagina for any abnormalities, collect tissue samples for further analysis, and diagnose and treat various conditions affecting the cervix and vagina.

2. 57454 CPT code description

The official description of CPT code 57454 is: “Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix and endocervical curettage.”

3. Procedure

1. The patient is placed in the dorsal lithotomy position.
2. A speculum is inserted and the cervix is cleaned of mucous with saline.
3. The entire length of the cervical canal, including the endocervix and exocervix, is inspected for visible abnormalities using a bright light.
4. A 3 to 5 percent solution of acetic acid is applied to the cervix and upper vagina to highlight lesions.
5. The colposcope is positioned and the entire cervical canal and upper vagina are inspected, using Q tips if needed to access tighter and higher areas in the cervix.
6. A green filter may be used to look for abnormal vascular patterns.
7. Lugol’s solution may be applied to the vagina and cervix to identify unstained tissue that needs to be sampled.
8. All lesions are biopsied and endocervical curettage is performed.
9. Bleeding from biopsy sites is treated with silver nitrate or Monsel’s solution.
10. The scope and speculum are withdrawn.

4. Qualifying circumstances

Patients eligible to receive CPT 57454 services are those who have abnormal cervical or vaginal findings, such as abnormal Pap smear results, visible lesions, or other indications of cervical or vaginal abnormalities. The procedure may also be performed for patients with a history of cervical or vaginal abnormalities, or those who are at an increased risk for developing such conditions.

5. When to use CPT code 57454

It is appropriate to bill the 57454 CPT code when a colposcopy of the cervix, including the upper/adjacent vagina, with biopsy(s) of the cervix and endocervical curettage is performed. This code should be used when the primary reason for the colposcopy is suspected lesions of the cervix, but the upper vagina is also examined. If a biopsy of the vagina is performed, a separate code (57100) can be reported with a modifier 59.

6. Documentation requirements

To support a claim for CPT 57454, the following information should be documented in the patient’s medical record:

• Indication for the procedure (e.g., abnormal Pap smear, visible lesions, etc.)
• Details of the procedure, including the use of acetic acid, Lugol’s solution, and any additional interventions
• Findings from the colposcopy, including the location and appearance of any abnormalities
• Details of the biopsy(s) and endocervical curettage, including the number and location of samples taken
• Treatment of bleeding from biopsy sites
• Post-procedure care instructions and follow-up plan

7. Billing guidelines

When billing for CPT code 57454, it is important to follow the appropriate guidelines and rules. If a colposcopy of the vulva (CPT codes 56820 and 56821) is performed in addition to CPT 57454, a modifier -51 should be added to the lower valued procedure. If a biopsy of the vagina is performed, a separate code (57100) can be reported with a modifier 59.

8. Historical information

CPT 57454 was added to the Current Procedural Terminology system on January 1, 1990. The code was changed on January 1, 2003, with the previous descriptor being “Colposcopy (vaginoscopy); with biopsy(s) of the cervix and/or endocervical curettage.”

9. Similar codes to CPT 57454

Five similar codes to CPT 57454 and how they differentiate are:

• CPT 57455: Colposcopy of the cervix only, without biopsy or endocervical curettage.
• CPT 57456: Colposcopy of the cervix with biopsy(s) only, without endocervical curettage.
• CPT 57460: Colposcopy of the cervix with loop electrode biopsy(s).
• CPT 56820: Colposcopy of the vulva, without biopsy.
• CPT 56821: Colposcopy of the vulva with biopsy(s).

10. Examples

Here are 10 detailed examples of CPT code 57454 procedures:

1. A patient with an abnormal Pap smear undergoes a colposcopy with biopsy of a suspicious cervical lesion and endocervical curettage.
2. A patient with a history of cervical dysplasia has a colposcopy with multiple biopsies of the cervix and endocervical curettage for further evaluation.
3. A patient with visible cervical lesions undergoes a colposcopy with biopsy of the lesions and endocervical curettage to rule out invasive disease.
4. A patient with persistent HPV infection has a colposcopy with biopsy of acetowhite areas on the cervix and endocervical curettage for further assessment.
5. A patient with postmenopausal bleeding undergoes a colposcopy with biopsy of a suspicious cervical lesion and endocervical curettage to determine the cause of bleeding.
6. A patient with a history of cervical cancer undergoes a colposcopy with biopsy of a recurrent lesion and endocervical curettage for staging purposes.
7. A patient with an abnormal cervical screening result has a colposcopy with biopsy of the transformation zone and endocervical curettage for further evaluation.
8. A patient with a suspicious cervical lesion on physical examination undergoes a colposcopy with biopsy of the lesion and endocervical curettage to confirm the diagnosis.
9. A patient with a history of cervical intraepithelial neoplasia has a colposcopy with biopsy of a new lesion and endocervical curettage for surveillance purposes.
10. A patient with a high-risk HPV infection undergoes a colposcopy with biopsy of the cervix and endocervical curettage to assess the extent of the disease.