LEEP / Cervical Conization
Colposcopy with loop electrosurgical excision procedure (LEEP) of the cervix [with endocervical curettage]
[HSIL ([CIN 2 / CIN 3 / CIN 2-3]) on colposcopy-directed biopsy / HSIL cytology, expedited treatment].
Informed consent was obtained after discussion of risks, including bleeding, infection, cervical stenosis, incomplete excision requiring further treatment, and preterm birth in a future pregnancy, as well as benefits and alternatives.
[***, MD/DO]
Local: [X] mL 1% lidocaine with epinephrine
Colposcopy after application of acetic acid [and Lugol's solution] showed acetowhite epithelium [with [mosaic / punctation / mosaic and punctation]] from [X] to [X] o'clock [with extension into the endocervical canal]. [No atypical vessels were seen.] The transformation zone was type [1 / 2 / 3].
[A urine pregnancy test was negative.] A time-out was completed confirming the patient and procedure. The patient was placed in the dorsal lithotomy position, and a grounding pad was applied to the thigh. An insulated, nonconductive speculum was placed, and a smoke evacuator was used throughout the procedure. Colposcopy was performed after application of acetic acid [and Lugol's solution], and the lesion and transformation zone were defined. A [intracervical / paracervical] block was placed.
The electrosurgical generator was set to [X] W blended cut. A [X]-cm loop was used to excise the lesion and transformation zone in a single pass[, followed by a second endocervical (top-hat) pass with a [X]-cm loop]. The specimen was [oriented with a suture at 12 o'clock and] placed in formalin. [Endocervical curettage was performed after the excision and sent separately.]
The base of the excision was fulgurated with the ball electrode at [X] W coagulation, and ferric subsulfate (Monsel's) paste was applied. Hemostasis was confirmed, and the speculum was removed.
Minimal
LEEP specimen[, oriented with a suture at 12 o'clock], to pathology
[Endocervical (top-hat) specimen, to pathology separately]
[Endocervical curettings, to pathology separately]
None
The patient tolerated the procedure well. She was instructed to maintain pelvic rest (no intercourse, tampons, or douching) for [X] weeks and to call for bleeding heavier than a menstrual period, fever, or foul-smelling discharge. Pathology results will be reviewed with her, and follow-up will be HPV-based testing at 6 months, then per ASCCP risk-based management guidelines.
Epic SmartPhrase Version
PROCEDURE: Colposcopy with LEEP of the cervix [with ECC]
INDICATION: [HSIL ([CIN 2 / CIN 3 / CIN 2-3]) on colposcopy-directed biopsy / HSIL cytology, expedited treatment].
CONSENT: Informed consent obtained after discussion of risks, including bleeding, infection, cervical stenosis, incomplete excision requiring further treatment, and preterm birth in a future pregnancy, benefits, and alternatives.
PERFORMED BY: ***, MD/DO
ANESTHESIA: Local: *** mL 1% lidocaine with epinephrine
FINDINGS: Colposcopy with acetic acid [and Lugol's]: acetowhite epithelium *** from *** to *** o'clock [with endocervical extension]. Transformation zone type [1 / 2 / 3].
PROCEDURE DETAILS:
[Urine pregnancy test negative.] Time-out completed. Dorsal lithotomy. Grounding pad applied to the thigh. Insulated speculum placed, smoke evacuator used throughout. Colposcopy performed, lesion and transformation zone defined. [Intracervical / Paracervical] block placed. Generator at *** W blended cut. *** cm loop, lesion and transformation zone excised in a single pass[, second endocervical (top-hat) pass with *** cm loop]. Specimen [oriented with 12 o'clock suture and] placed in formalin. [ECC after excision, sent separately.] Base fulgurated with ball electrode at *** W coagulation. Monsel's applied. Hemostasis confirmed.
EBL: Minimal
SPECIMENS: LEEP specimen [with 12 o'clock suture][, top-hat specimen separately][, ECC separately] to pathology
COMPLICATIONS: None
POST-PROCEDURE PLAN: Tolerated well. Pelvic rest *** weeks. Bleeding precautions given. Pathology to be reviewed with patient. HPV-based testing at 6 months, then per ASCCP.
Signed: .ME, .MYDEGREE
.TODAYVariants
Cold Knife Conization (Operating Room)
Cold knife conization of the cervix was performed in the operating room under [general / regional] anesthesia. After a time-out, the patient was placed in the dorsal lithotomy position, prepped, and draped, and the bladder was drained. A weighted speculum was placed. Lateral stay sutures of [0 Vicryl] were placed at 3 and 9 o'clock[, and dilute vasopressin was injected circumferentially into the cervical stroma]. [Lugol's solution was applied to define the lesion.]
A circumferential incision was made outside the lesion with a [#11 / #15] blade, and the cone was excised to a depth of [X] cm. The specimen was oriented with a suture at 12 o'clock and sent to pathology. [Endocervical curettage was performed above the cone and sent separately.] Hemostasis was achieved with electrocautery [and [ferric subsulfate (Monsel's) paste / Sturmdorf sutures]].
Charting Tips
- Document LEEP specimen orientation. Pathologists require orientation to map margin involvement by location. Note that a [12 o'clock] suture or marking ink was applied before the specimen was placed in formalin. An unoriented specimen still reports margin status but cannot localize a positive margin.
- Document the transformation zone type. ASCCP 2019 risk-based guidelines tie ablation eligibility to TZ type, although excision is preferred over ablation for histologic HSIL (CIN 2 or CIN 3) in the United States:
- Type 1 (fully ectocervical and fully visible): ablation is acceptable only when all eligibility criteria are met (no suspicion of invasion or AIS, lesion fully visible, no endocervical extension).
- Type 2 (partly endocervical but fully visible): ablation is acceptable only if the upper limit of the lesion is fully visible.
- Type 3 (squamocolumnar junction not fully visible): excision is required, and the cone should be deeper or a top-hat pass added.
A type 3 TZ in the findings documents why excision rather than ablation was performed.
- Record electrosurgical safety steps (grounding pad, insulated speculum, smoke evacuation) and generator settings. The electrosurgical plume contains HPV DNA, so state that a smoke evacuator was used.
- Send the post-excision ECC as a separate specimen from the cone. It samples the canal above the endocervical margin, and residual disease there changes surveillance and re-excision decisions independently of the margin result.
- Excision depth over 10 mm is associated with a higher risk of preterm birth. In patients planning pregnancy, match loop size and depth to the TZ type and document the loop dimensions.
- Cold knife conization is preferred when adenocarcinoma in situ or microinvasion is suspected, because it yields an intact specimen with margins free of thermal artifact. Document the indication when choosing it over LEEP.
Documentation & Reimbursement Considerations
- Primary service: Report LEEP / Cervical Conization as the primary service when it is the definitive operation performed.
- Cold-knife conization and loop conization performed under anesthesia carry 90-day global periods; colposcopic loop biopsy and excision procedures carry 0-day global periods.
- Loop excision is coded by whether the endocervical canal was excised (conization, 3.34 wRVU) or only the ectocervix and transformation zone (2.76 wRVU), and the two are not reported together on the same cervix. Document explicitly which tissue was removed and each component performed (colposcopy, ECC, LEEP). A same-day E/M is billable only when a distinct evaluation is documented.
- Endocervical curettage (ECC) performed at the time of LEEP is typically bundled and is not billed separately. Document ECC performed as part of the procedure note.
- Repeat LEEP for positive margins is a new billable procedure, not within any global period of the first LEEP. Document the pathology result that indicated re-excision.