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Basics about LEEP CPT code 57460 & 57461

LEEP stands for Loop Electrosurgical Excision Procedure. It is done for treatment of cervical cancer. In this exam, an electrical wire loop is used for removing abnormal cells from your cervix. LEEP exam is done once any abnormality was seen during a pap test, colposcopy or biopsy. We have learnt about breast biopsy, thyroid biopsy and also about Fine needle aspiration CPT codes previously.

The procedure used to examine your cervix, vagina and vulva for any sign of disease is called colposcopy. The physician is performed by using a colposcope. A colposcopy is always recommended when there is any abnormality found during a pap test. In medical coding, there are separate CPT code 57460 & 57461, for coding colposcopy with LEEP exam.

Codes for conization (cone biopsy) of the cervix are divided on the basis of the method used to obtain the tissue . In conization, a cone of tissue is removed from the cervix for a biopsy or treatment of a lesion by means of excision of the lesion. Although a laser is a frequently used method of conization, LEEP technology is also widely used. The code for a LEEP procedure with cervical biopsy in the Cervix Uteri subheading, Endoscopy category, is 57460, and the code for a LEEP procedure with cervical conization is 57461.

The difference between the codes is that the cervical biopsy procedure only removes a sample with return in the future if the lesion is to be completely removed. The conization procedure removes a cone-shaped tissue of the cervix after application of iodine to highlight the abnormal tissue. Also, the cervical biopsy is performed with the use of a colposcope (endoscopy), and the conization is performed using a speculum (an instrument inserted into a cavity to stretch the opening).

Be certain, when coding cervical biopsy and conization, that the information in the medical record provides sufficient detail to allow you to distinguish between a biopsy and a conization. If the record is not complete enough to make the determination, obtain the information from the physician before assigning a code.

We have learnt a lot about complicate surgeries like ,hip arthroplasty knee repair, hernia repair etc. hence this exam can be easily coded by coders.

Description of CPT code 57460 & 57461

Before we move ahead we have to first understand the difference between a biopsy and conization. A biopsy is a exam to remove a piece of tissue or a sample of cells from your body so that it can be analyzed in a laboratory & conization refers to the removal of a cone-shaped section of tissue from the cervix. CPT code 57460 & 57461 has this minute difference between them.

Following the colposcopy procedure, the patient is placed on a grounding pad and an insulated speculum connected to smoke-evacuator tubing is inserted into the vagina. The cervix is visualized and a local anesthetic with epinephrine is injected beneath the surface of the cervical epithelium. Abnormal tissue is biopsied (CPT code 57460) using the thin wire loop that conducts the electrical current. Alternatively, a loop electrode conization of the cervix may be performed, for procedure code 57461.

57460 – Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s) of the cervix

57461 – Colposcopy of the cervix including upper/adjacent vagina; with loop electrode conization of the cervix

For CPT code 57460, the physician inserts a speculum into the vagina to fully expose and examine the cervix to identify abnormal cells. The upper/adjacent portion of the vagina is examined through a colposcope and a binocular microscope is used for direct visualization of the vagina, ectocervix, and endocervix. The physician swabs the vaginal walls and cervix with vinegar or another type of solution (acetic acid) to remove mucus and highlight abnormal cells by turning them white, making them more easily identifiable for possible biopsy. Sometimes a Schiller test, iodine solution used to coat the cervix, is performed.

The solution may cause a slight tingling or burning sensation. Local anesthesia may be used to numb the area. A biopsy specimen of cervical tissue is removed by the loop electrode excision procedure (LEEP). LEEP uses a thin wire loop carrying an electrical cutting current that acts as a cutting instrument to remove abnormal cells. Due to the electrical current, a grounding pad is attached to the patient’s leg during the procedure. The physician may apply Monsel’s solution, a special type of paste that helps to seal blood vessels to prevent bleeding.

For CPT code 57461, Using the loop, the lesion and transformation zone (the boundary of the excision to assure complete removal of the dysplasia) is removed as one specimen. If the lesion is large and another pass is required, two equal specimens are removed and labeled for the axis of orientation. The same procedure is done again with a smaller loop if an endocervical excision is necessary. The physician may apply Monsel’s solution, a special type of paste that helps to seal blood vessels to prevent bleeding or bleeding vessels are cauterized. The vagina is inspected for any accidental injury and the instruments are removed.

For laboratory exam, we have to 80000 series CPT codes for cervix biopsy and conization. CPT code 88305 & 88307 are used for coding laboratory exam for cervix.

88305 – Surgical pathology, gross and microscopic examination, cervix, biopsy

88307 – Surgical pathology, gross and microscopic examination, cervix, conization

Supply Codes used with CPT code 57460 and 57461

SA048 pack, minimum multi-specialty visit
SA051 pack, pelvic exam
SB006 drape, non-sterile, sheet 40in x 60in
SB024 gloves, sterile
SC028 needle, 18-26g 1.5-3.5in, spinal
SC029 needle, 18-27g
SC063 syringe-needle 10ml 26g
SD134 tubing, suction, non-latex (6ft) with Yankauer tip (1)
SF014 cautery, electrode extender
SF017 cautery, monopolar, electrode, loop
SF019 cautery, monopolar, electrode, spatula
SF020 cautery, monopolar, pencil-handpiece
SF021 cautery, patient ground pad w-cord
SG008 applicator, cotton-tipped, non-sterile 6in
SH001 acetic acid 5%
SH047 lidocaine 1%-2% inj (Xylocaine)
SJ036 Monsel’s soln
SJ041 povidone soln (Betadine)
SJ046 silver nitrate applicator
SJ053 swab-pad, alcohol
SL036 cup, biopsy-specimen sterile 4oz
SL136 stain, Lugol’s
SM002 autoclave bag
SM003 autoclave tape