Annie Posted Wed 28th of September, 2016 08:47:55 AM
Would this be 57460? Getting confused with the codes.
The patient was taken to OR where she was found to be adequate. She was prepped and draped in a normal sterile fashion. Her legs were placed in candy cane stirrups. A coated speculum was placed into
the vagina and the cervix was noted as above. Acetic Acid was then applied to the vagina and areas were identified. I then took an electric wire loop and on 35/35 blend, dissected off of a portion of the cervix. The specimen was then sutured at 12 o'clock. I then proceeded to take a rollerball Bovie and bovied the edges of the tissue and hemostasis was noted.
SuperCoder Answered Thu 29th of September, 2016 05:55:42 AM
In the provided document, patient's portion of cervix is being taken and no curettage is done. So, the code chosen by you is correct. In CPT 57460, the physician views the cervix, including the upper/adjacent portion of the vagina through a colposcope, a binocular microscope used for direct visualization of the vagina, ectocervix, and endocervix. The physician inserts a speculum into the vagina to fully expose the cervix, as done in your case. A biopsy specimen of cervical tissue is removed by the loop electrode excision procedure. A hot cautery wire containing an electrical cutting current as a cutting instrument to take the part of the cervix. Check your documentation thoroughly, if endocervical curettage is being done, then use the CPT 57456.