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Ob-Gyn Coding Alert

You Be the Coder:

Biopsy Without Colposcopy

Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.

Question: What is the correct way to code a loop electrode excision procedure (LEEP) biopsy when the ob-gyn does not use a colposcope? Minnesota Subscriber

Answer: You should use 57500* (Biopsy, single or multiple, or local excision of lesion, with or without fulguration [separate procedure]) for a cervical biopsy without colposcopy. In fact, you should use 57500 for obtaining a cervical biopsy by any method. You may be tempted to use 57460 (Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy[s] of the cervix) appended with modifier -52 (Reduced services). But if the physician routinely does not use a colposcope, then adding the modifier each time the doctor performs the procedure will get you flagged by payers, and you will have the additional hassle of sending in documentation with each claim to explain what represented the reduced services. In addition, the modifier likely will slow the claims' processing time.  

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