How To Use CPT Code 56820

CPT 56820 describes the procedure of colposcopy of the vulva, which involves the examination of the external genital area of a female patient for any abnormalities or lesions. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 56820?

CPT 56820 is used to describe the procedure of colposcopy of the vulva. During this procedure, a healthcare provider inserts a colposcope, which is an endoscope, into the vulva to examine it for any abnormalities or lesions. The provider uses different magnification levels and may use a green filter to inspect the entire vulva thoroughly.

2. Official Description

The official description of CPT code 56820 is: ‘Colposcopy of the vulva.’

3. Procedure

1. The patient is placed in a normal lithotomy position, lying on her back with knees bent and positioned above the hips, and spread apart through the use of stirrups.
2. The provider cleans the vulva with a 3 to 5 percent acetic acid solution, such as vinegar, which will turn any abnormal areas white.
3. The provider positions the colposcope about 30 cm from the vulva and uses different magnification levels to inspect the entire vulva for any abnormalities or suspicious lesions.
4. A green filter may be used to look for abnormal vascular patterns.
5. If no lesions or abnormalities are found, the provider reassesses the patient but does not perform a biopsy.

4. Qualifying circumstances

CPT 56820 is performed when a healthcare provider needs to examine the vulva for any abnormalities or lesions. This procedure is typically done to evaluate and diagnose conditions such as vulvar cancer, vulvar intraepithelial neoplasia (VIN), or other vulvar abnormalities. It is important to note that this code specifically refers to the colposcopy of the vulva and not other areas such as the vagina or cervix.

5. When to use CPT code 56820

CPT code 56820 should be used when a healthcare provider performs a colposcopy specifically on the vulva. It is important to ensure that the procedure is documented accurately and that it is clear that the examination was focused on the vulva and not other areas. If the colposcopy involves the examination of the vagina or cervix, different codes should be used.

6. Documentation requirements

To support a claim for CPT 56820, the healthcare provider must document the following information:

• Reason for performing the colposcopy of the vulva
• Details of the procedure, including the use of a colposcope and any additional tools or techniques
• Findings of the examination, including any abnormalities or lesions
• Any additional actions taken during the procedure, such as biopsies or treatments
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 56820, ensure that the procedure performed is specifically the colposcopy of the vulva. It is important to accurately document the details of the procedure and any additional actions taken. If the colposcopy involves the examination of other areas, different codes should be used. It is also important to follow any specific billing guidelines provided by insurance companies or payers.

8. Historical information

CPT 56820 was added to the Current Procedural Terminology system on January 1, 2003. It underwent a code change on January 1, 2010, with the description being updated to ‘Colposcopy of the vulva.’

9. Examples

1. A healthcare provider performs a colposcopy of the vulva on a patient with suspected vulvar cancer.
2. During a routine examination, a healthcare provider performs a colposcopy of the vulva to evaluate and diagnose any vulvar abnormalities.
3. A patient presents with symptoms of vulvar intraepithelial neoplasia (VIN), and a healthcare provider performs a colposcopy of the vulva to assess the extent of the condition.
4. As part of a comprehensive evaluation, a healthcare provider performs a colposcopy of the vulva to rule out any vulvar lesions or abnormalities.
5. A patient with a history of vulvar abnormalities undergoes a colposcopy of the vulva for surveillance purposes.
6. During a follow-up visit, a healthcare provider performs a colposcopy of the vulva to monitor the progress of a previously identified vulvar lesion.
7. A healthcare provider performs a colposcopy of the vulva on a patient with persistent vulvar itching and discomfort.
8. As part of a diagnostic workup, a healthcare provider performs a colposcopy of the vulva to investigate the cause of unexplained vulvar symptoms.
9. A patient with a family history of vulvar cancer undergoes a colposcopy of the vulva as a preventive measure.
10. A healthcare provider performs a colposcopy of the vulva on a patient with a history of abnormal Pap smears to further evaluate any potential vulvar abnormalities.