How To Use CPT Code 57460

CPT 57460 describes the procedure of colposcopy of the cervix, including the upper/adjacent vagina, with loop electrode biopsy(s) of the cervix. 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 57460?

CPT 57460 is used to describe the colposcopy procedure of the cervix, including the upper/adjacent vagina, with loop electrode biopsy(s) of the cervix. This code is used when a healthcare provider uses a colposcope to examine the cervix and performs a biopsy using a loop electrode to obtain tissue samples for further analysis.

2. Official Description

The official description of CPT code 57460 is: ‘Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s) of the cervix.’

3. Procedure

1. The patient is positioned in the dorsal lithotomy position.
2. A speculum is inserted to hold the vaginal walls apart.
3. The provider cleans the cervix with saline to remove mucus.
4. The provider inspects the entire length of the cervical canal using a colposcope, a magnifying instrument with a bright light.
5. A solution of acetic acid (vinegar) is applied to the cervix and upper vagina to highlight any abnormalities.
6. The provider uses the colposcope to examine the cervix and upper, adjacent area of the vagina for visible abnormalities.
7. If necessary, the provider may apply Lugol’s solution to the vagina and cervix to identify unstained tissue for sampling.
8. The provider determines the size of the lesion and injects lidocaine into the cervix for anesthesia.
9. A loop electrode is used to excise the lesion on the ectocervix and transformation zone, if needed, with adequate margins.
10. Bleeding is controlled using electrocautery and Monsel’s solution.

4. Qualifying circumstances

CPT 57460 is performed when a patient requires colposcopy of the cervix, including the upper/adjacent vagina, with loop electrode biopsy(s). This procedure is typically performed when there are suspected abnormalities or lesions on the cervix that require further evaluation and tissue sampling. It is important to note that this procedure should only be performed by a qualified healthcare provider with expertise in colposcopy.

5. When to use CPT code 57460

CPT code 57460 should be used when a healthcare provider performs a colposcopy of the cervix, including the upper/adjacent vagina, and performs loop electrode biopsy(s) of the cervix. This code should be used when the procedure meets the specific criteria outlined in the official description.

6. Documentation requirements

To support a claim for CPT code 57460, the healthcare provider must document the following information:

• Patient’s medical history and reason for the procedure
• Details of the colposcopy procedure, including the use of a colposcope and any solutions applied
• Date and duration of the procedure
• Specific findings and abnormalities observed during the procedure
• Details of the loop electrode biopsy(s), including the size of the lesion and margins
• Any additional procedures performed, such as electrocautery or the use of Monsel’s solution
• Any complications or adverse events
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT code 57460, ensure that the procedure meets the specific criteria outlined in the official description. It is important to use the appropriate code for the specific procedure performed. If additional procedures, such as colposcopy of the vulva, are performed in addition to CPT code 57460, modifiers may be required to indicate the additional procedures.

8. Historical information

CPT code 57460 was added to the Current Procedural Terminology system on January 1, 1993. There have been historical changes to the code, including a code change on January 1, 2003, which replaced the term “loop electrode excision procedure” with “loop electrode biopsy(s) of the cervix.”

9. Examples

1. A healthcare provider performs a colposcopy of the cervix, including the upper/adjacent vagina, and performs loop electrode biopsy(s) to obtain tissue samples for further analysis.
2. During a routine gynecological examination, a suspicious lesion is identified on the cervix, prompting the healthcare provider to perform a colposcopy with loop electrode biopsy(s) for further evaluation.
3. A patient with a history of abnormal Pap smear results undergoes a colposcopy of the cervix, including the upper/adjacent vagina, with loop electrode biopsy(s) to assess the extent of any abnormalities.
4. Following an abnormal cervical biopsy result, a healthcare provider performs a colposcopy with loop electrode biopsy(s) to obtain additional tissue samples for a more accurate diagnosis.
5. A patient with persistent HPV infection undergoes a colposcopy of the cervix, including the upper/adjacent vagina, with loop electrode biopsy(s) to assess the presence of any precancerous or cancerous cells.
6. During a follow-up examination after a previous colposcopy, a suspicious lesion is identified on the cervix, prompting the healthcare provider to perform a repeat colposcopy with loop electrode biopsy(s) for further evaluation.