How To Use CPT Code 57461

CPT 57461 describes the procedure of colposcopy of the cervix, including the upper/adjacent vagina, with loop electrode conization of the cervix. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 57461?

CPT 57461 is used to describe the colposcopy procedure of the cervix, which includes the examination of the upper/adjacent vagina. During this procedure, a loop electrode conization of the cervix is also performed. It is important to note that CPT 57461 should not be reported in addition to CPT 57456.

2. Official Description

The official description of CPT code 57461 is: ‘Colposcopy of the cervix including upper/adjacent vagina; with loop electrode conization of the cervix.’ It is important to remember that CPT code 57465 should be used for computer-aided mapping of the cervix uteri during colposcopy, and CPT code 58110 should be used for endometrial sampling (biopsy) performed in conjunction with colposcopy.

3. Procedure

1. The patient is placed in the dorsal lithotomy position.
2. A speculum is inserted, and the cervix is cleaned with saline to remove mucus.
3. The provider inspects the entire length of the cervical canal, including the endocervix and exocervix, for any visible abnormalities using a bright light.
4. A 3 to 5 percent solution of acetic acid (such as vinegar) is applied to the cervix and upper vagina to highlight any lesions.
5. The provider uses a colposcope to examine the entire cervical canal, using Q tips if necessary to access tighter and higher places in the cervix.
6. A green filter may be used to look for abnormal vascular patterns.
7. Lugol’s solution (also known as Schiller’s test) may be applied to the vagina and cervix to identify unstained tissue that needs to be sampled.
8. The provider determines the size of the lesion and places a grounding pad.
9. Lidocaine is injected into the cervix to provide local anesthesia.
10. An appropriately sized loop electrode is used to excise the lesion on the ectocervix with adequate margins.
11. A second loop may be used to remove the involved portion of the endocervix.
12. Bleeding is controlled using electrocautery and Monsel’s solution.

4. Qualifying circumstances

CPT 57461 is performed when a provider needs to examine the cervix, including the upper/adjacent vagina, using a colposcope. This procedure is typically done when there are suspected lesions or abnormalities in the cervix. The loop electrode conization of the cervix is performed to remove the exocervix, transformation zone, and all or part of the endocervix. It is important to note that CPT 57461 should not be reported in addition to CPT 57456.

5. When to use CPT code 57461

CPT code 57461 should be used when a provider performs a colposcopy of the cervix, including the upper/adjacent vagina, and performs a loop electrode conization of the cervix. It is important to note that CPT 57461 should not be reported in addition to CPT 57456.

6. Documentation requirements

To support a claim for CPT 57461, the provider must document the following information:

• Patient’s diagnosis or reason for the colposcopy procedure
• Details of the colposcopy procedure, including the use of a colposcope and loop electrode conization
• Date of the procedure
• Start and end time of the procedure
• Any abnormalities or lesions observed during the procedure
• Size of the lesion and margins excised
• Details of any local anesthesia used
• Method used to control bleeding
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 57461, ensure that the procedure includes the colposcopy of the cervix, including the upper/adjacent vagina, and the loop electrode conization of the cervix. It is important to note that CPT 57461 should not be reported in addition to CPT 57456. If colposcopy of the vulva (CPT codes 56820 and 56821) is performed in addition to CPT 57461, a modifier -51 should be added to the lower valued procedure.

8. Historical information

CPT 57461 was added to the Current Procedural Terminology system on January 1, 2003. There have been no updates to the code since its addition.

9. Examples

1. A provider performs a colposcopy of the cervix, including the upper/adjacent vagina, and performs a loop electrode conization of the cervix to remove a suspicious lesion.
2. During a colposcopy procedure, a provider identifies abnormal areas in the cervix and performs a loop electrode conization to remove the affected tissue.
3. A patient undergoes a colposcopy procedure, which includes the examination of the cervix and upper/adjacent vagina, as well as a loop electrode conization to remove abnormal cells.
4. During a colposcopy, a provider uses a colposcope to examine the cervix and upper/adjacent vagina, and performs a loop electrode conization to remove a precancerous lesion.