How To Use CPT Code 57500

CPT 57500 refers to a biopsy or local excision of the cervix, with or without fulguration, 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 57500?

CPT 57500 is a medical procedure code used to describe the biopsy or local excision of the cervix, with or without the use of fulguration. This code is utilized by medical professionals to accurately document and bill for this specific procedure, ensuring proper reimbursement and record-keeping.

2. 57500 CPT code description

The official description of CPT code 57500 is: “Biopsy of cervix, single or multiple, or local excision of lesion, with or without fulguration (separate procedure)”.

3. Procedure

The 57500 CPT code procedure involves the following steps:

1. The patient is placed in a dorsal lithotomy position.
2. A speculum is inserted to visualize the cervix.
3. Acetic acid or saline is applied to the cervix to remove mucus, debris, and blood.
4. The provider identifies the location of abnormal tissue or a lesion.
5. Biopsy forceps are used to remove single or multiple pieces of tissue, or the entire lesion may be excised.
6. Depending on the abnormality of the lesion(s), the provider may destroy the abnormal tissues using high-frequency electric current (fulguration).
7. Bleeding is controlled, and the speculum is removed.

4. Qualifying circumstances

Patients eligible to receive CPT code 57500 services are those who present with abnormal cervical tissue or lesions that require biopsy or excision. This may include patients with abnormal Pap smear results, those with visible cervical abnormalities during a pelvic examination, or those with a history of cervical dysplasia or cancer. The decision to perform this procedure is based on the provider’s clinical judgment and the patient’s specific medical history and needs.

5. When to use CPT code 57500

It is appropriate to bill the 57500 CPT code when a provider performs a biopsy or local excision of the cervix, with or without fulguration, as a separate procedure. This code should not be used when the biopsy or excision is performed as part of another procedure, as it may be bundled into the primary procedure code.

6. Documentation requirements

To support a claim for CPT 57500, the following information should be documented in the patient’s medical record:

• Indication for the procedure, such as abnormal Pap smear results or visible cervical abnormalities.
• Detailed description of the procedure, including the use of a speculum, application of acetic acid or saline, biopsy or excision technique, and use of fulguration if applicable.
• Findings during the procedure, including the location and appearance of abnormal tissue or lesions.
• Number of biopsies taken or the size of the excised lesion.
• Post-procedure care, including bleeding control and speculum removal.
• Pathology report, if applicable, to confirm the diagnosis.

7. Billing guidelines

When billing for CPT code 57500, it is essential to follow specific guidelines and rules to ensure proper reimbursement. These include:

• Verify that the procedure is not bundled into another procedure, as 57500 is a separate procedure code.
• Ensure that all required documentation is present in the patient’s medical record to support the claim.
• Check for any applicable modifiers that may need to be added to the code, such as -59 for a distinct procedural service.

8. Historical information

CPT 57500 was added to the Current Procedural Terminology system on January 1, 1990. The code was changed on January 1, 2008, with the previous descriptor being “Biopsy, single or multiple, or local excision of lesion, with or without fulguration (separate procedure)”.

9. Similar codes to CPT 57500

Five similar codes to CPT 57500 and how they differentiate are:

1. CPT 57452: This code is for a colposcopy of the cervix, which involves visual examination of the cervix using a colposcope but does not include biopsy or excision.
2. CPT 57454: This code is for a colposcopy of the cervix with biopsy, which includes both the visual examination and the biopsy but not excision or fulguration.
3. CPT 57455: This code is for a colposcopy of the cervix with loop electrode biopsy, which involves the use of a loop electrode to remove tissue for biopsy.
4. CPT 57456: This code is for a colposcopy of the cervix with loop electrode excision, which involves the use of a loop electrode to excise a lesion.
5. CPT 57505: This code is for an endocervical curettage, which involves the removal of tissue from the endocervical canal using a curette but does not include biopsy or excision of the cervix.

10. Examples

Here are 10 detailed examples of CPT code 57500 procedures:

1. A patient with an abnormal Pap smear result undergoes a cervical biopsy using biopsy forceps to remove multiple tissue samples.
2. A patient with a visible cervical polyp has the polyp excised using a scalpel, without the use of fulguration.
3. A patient with a history of cervical dysplasia undergoes a cervical biopsy with fulguration to destroy any remaining abnormal tissue.
4. A patient with a Nabothian cyst has the cyst excised, and the provider uses fulguration to control bleeding.
5. A patient with a suspicious cervical lesion undergoes a cervical biopsy, with multiple tissue samples taken using biopsy forceps.
6. A patient with a large cervical lesion has the lesion excised using a scalpel, followed by fulguration to destroy any remaining abnormal tissue.
7. A patient with recurrent cervical dysplasia undergoes a cervical biopsy with fulguration to remove and destroy abnormal tissue.
8. A patient with a visible cervical abnormality undergoes a cervical biopsy, with a single tissue sample taken using biopsy forceps.
9. A patient with a history of cervical cancer undergoes a cervical biopsy to monitor for recurrence, with multiple tissue samples taken using biopsy forceps.
10. A patient with a suspicious cervical lesion undergoes a cervical excision, with the entire lesion removed using a scalpel and fulguration to control bleeding.