Ob-Gyn Coding Alert

Pull out key phrases to ensure you’re selecting the most accurate choice.

Your colposcopy coding choices are numerous, and so are the chances of picking the wrong code, which could cost you money. Take this challenge and see if you pick the proper CPT® and ICD-10-CM code in each instance.

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Clue: Zoom in on what your ob-gyn did in addition to the colposcope — biopsy, endocervical curettage, or loop electrocautery excision procedure (LEEP)?

Scenario 1: Highlight These 3 Important Phrases

You receive an encounter note, where your ob-gyn states: “I cleansed the cervix, including upper/adjacent vagina, several times with 3 percent acetic acid. After adequate time for the acetic acid effect, I examined the cervix and vaginal fornices with a colposcope at several magnifications. I looked at the transformation zone completely.

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“I noted an abnormality consisting of leukoplakia, mosaicism, punctuation, or atypical vessels during the exam. At noon, the patient had abnormal acetowhite areas extending into the endocervical canal, and I took a cervical biopsy. I treated the biopsy site with Monsel’s solution or silver nitrate for hemostasis.”

What CPT® and ICD-10 codes should you report in this situation?

Solution 1: First, you should isolate the important information. According to Peggy Stilley, CPC, CPB, CPMA, CPC-I, COBGC, presenter of “Gynecology in the Office” at this 2021’s Charleston Regional AAPC Conference, critical phrases are:

• “including upper/adjacent vagina”
• “transformation zone completely”
• cervical biopsy at noon

CPT®: Narrow down your coding options. From the first phrase, you know to look at the codes that “describe the inspection of the cervix with upper/ adjacent vagina,” Stilley says.

Therefore, your options are 57454 (Colposcopy of the cervix including upper/ adjacent vagina; with biopsy[s] of the cervix and endocervical curettage), 57455 (… with biopsy[s] of the cervix), 57456 (… with endocervical curettage), 57460 (… with loop electrode biopsy(s) of the cervix), or 57461 (… with loop electrode conization of the cervix). “Your decision depends on the additional procedure the ob-gyn does, whether it is a biopsy, endocervical curettage (ECC), LEEP excision, and so on,” Stilley says.

In this case, the ob-gyn performed only a biopsy, hence the third phrase: “cervical biopsy at noon.” However, you still don’t have enough information because this note does not specify what equipment the ob-gyn used to obtain the biopsy – a scalpel or punch biopsy tool or an electrical wire loop. If the former, you should report 57455 for this procedure; if the latter, 57460 would be the correct code.

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Note: The difference between a LEEP biopsy and a LEEP cone is that in a biopsy the ob-gyn takes only the transformation zone, but with a LEEP cone, she takes the transformation zone plus the endocervix.

ICD-10: Although you also need more information to choose your ICD-10 diagnosis code appropriately (because you must always base it on the physician’s documentation), here are the likely codes: R87.610-R87.611 (Atypical squamous cells …), R87.615 (Unsatisfactory cytologic smear of cervix), R87.810 (Cervical high risk human papillomavirus (HPV) DNA test positive), R87.811 (Vaginal high risk human papillomavirus (HPV) DNA test positive), or R87.820 (Cervical low risk human papillomavirus (HPV) DNA test positive). In other words, you must know what Pap results from a previous encounter determined the need for the colposcopy.

Scenario 2: Keep Similarities With First Procedure in Mind

Your ob-gyn’s documentation states: “I cleansed the cervix, including upper/adjacent vagina, several times with 3 percent acetic acid. After adequate time for the acetic acid effect, I examined the cervix and vaginal fornices with a colposcope at several magnifications. I looked at the transformation zone completely. I noted abnormal acetowhite areas at noon, extending into the endocervical canal.

“I performed an endocervical curettage and cervical biopsy. I treated the biopsy site with Monsel’s solution or silver nitrate for hemostasis.”

What CPT® and ICD-10 codes should you report in this situation?

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