How To Use CPT Code 57065

CPT 57065 describes the extensive destruction of vaginal lesions using various methods such as laser surgery, electrosurgery, cryosurgery, or chemosurgery. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 57065?

CPT 57065 is used to describe the destruction of one or more large or complex vaginal lesions. This procedure involves the use of techniques such as laser surgery, electrosurgery, cryosurgery, or chemosurgery to remove the lesions. It is typically performed when the lesions are extensive and require significant treatment.

2. Official Description

The official description of CPT code 57065 is: ‘Destruction of vaginal lesion(s); extensive (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery).’

3. Procedure

1. The patient is positioned in the dorsal lithotomy position.
2. A local anesthetic is applied to the vaginal mucosa.
3. The provider identifies the location of the lesion(s).
4. The provider uses laser surgery, electrosurgery, cryosurgery, or chemosurgery to destroy the lesion(s).
5. In laser surgery, the provider vaporizes the lesion tissue using a high beam of light.
6. In electrosurgery, the provider uses a monopolar or bipolar instrument to destroy the lesion(s).
7. In cryosurgery, the provider applies liquid nitrogen to the lesion(s) with repetitive freeze and thaw cycles.
8. In chemosurgery, the provider applies a chemical to the lesion(s) and removes the destroyed tissue.
9. The procedure is repeated for any additional vaginal lesions that may be present.

4. Qualifying circumstances

CPT 57065 is used when the vaginal lesions are large, complex, or greater than three in number and require extensive treatment. The procedure is performed by a qualified healthcare professional using techniques such as laser surgery, electrosurgery, cryosurgery, or chemosurgery.

5. When to use CPT code 57065

CPT code 57065 should be used when the provider is performing an extensive destruction of vaginal lesions using methods such as laser surgery, electrosurgery, cryosurgery, or chemosurgery. It is important to ensure that the lesions are large, complex, or greater than three in number and require extensive treatment.

6. Documentation requirements

To support a claim for CPT 57065, the healthcare professional must document the following information:

• Patient’s diagnosis and the need for extensive destruction of vaginal lesions
• Specific method used for the destruction (laser surgery, electrosurgery, cryosurgery, or chemosurgery)
• Date of the procedure
• Details of the procedure, including the number and size of lesions treated
• Any complications or additional procedures performed
• Signature of the healthcare professional performing the procedure

7. Billing guidelines

When billing for CPT 57065, ensure that the procedure meets the criteria for extensive destruction of vaginal lesions. It is important to use the appropriate code based on the method used (laser surgery, electrosurgery, cryosurgery, or chemosurgery). Report code 57061 for the destruction of simple lesions. It is also important to follow any specific billing guidelines provided by the payer.

8. Historical information

CPT 57065 was added to the Current Procedural Terminology system on January 1, 1990. The code was later revised on January 1, 2002 to include any method of extensive destruction of vaginal lesions.

9. Examples

1. A provider using laser surgery to extensively destroy multiple vaginal lesions in a patient.
2. A provider performing electrosurgery to treat large and complex vaginal lesions in a patient.
3. A provider using cryosurgery to destroy extensive vaginal lesions in a patient.
4. A provider performing chemosurgery to treat multiple large vaginal lesions in a patient.
5. A provider using a combination of laser surgery, electrosurgery, cryosurgery, and chemosurgery to extensively destroy complex vaginal lesions in a patient.
6. A provider using laser surgery to treat extensive vaginal lesions in a patient with a specific diagnosis.
7. A provider performing electrosurgery to destroy multiple large vaginal lesions in a patient with a specific condition.
8. A provider using cryosurgery to extensively treat complex vaginal lesions in a patient with a specific diagnosis.
9. A provider performing chemosurgery to destroy extensive vaginal lesions in a patient with a specific condition.
10. A provider using a combination of laser surgery, electrosurgery, cryosurgery, and chemosurgery to extensively treat complex vaginal lesions in a patient with a specific diagnosis.