LEEP (Loop Electrosurgical Excision Procedure) / Cervical Cone Biopsy
5746157460wRVU: 2.76 — Colposcopy with loop electrode biopsy of cervix (ectocervix only, no endocervical excision) — mutually exclusive with 57461; use when endocervix is NOT removed (2.76 wRVU, 0-day global)57520wRVU: 4.01 — Conization of cervix, cold knife or laser (CKC), with or without fulguration/D&C/repair (4.01 wRVU, 90-day global)57522wRVU: 3.58 — Conization of cervix with loop electrode excision (LEEP-cone), performed under anesthesia in OR (3.58 wRVU, 90-day global)
Cervical high-grade squamous intraepithelial lesion (HSIL / CIN 2-3), confirmed on colposcopy-directed biopsy
Same
LEEP (loop electrosurgical excision procedure) [/ cold knife cone biopsy] with endocervical curettage
[Attending name], MD/DO
[Nurse/tech name]
Local: [X] mL 1% lidocaine with 1:100,000 epinephrine [paracervical block and intracervical injection]
The patient is a [age]-year-old [female] with HSIL [CIN 2 / CIN 3] confirmed on colposcopy-directed biopsy. The transformation zone was [completely / not completely] visualized. LEEP was recommended for excisional treatment. The risks, benefits, and alternatives including ablation and observation were discussed and informed consent was obtained.
Colposcopy with acetic acid application demonstrated [acetowhite lesion / mosaic / punctation] extending to the [3 and 9 o'clock positions / entire circumference] of the ectocervix, involving the [ectocervix / endocervix]. The squamocolumnar junction was [fully visualized (Type 1) / not fully visualized (Type 3)]. The LEEP specimen measured [X × X × X] cm. [Endocervical curettage was [negative for dysplasia / positive for HSIL / nondiagnostic (insufficient tissue)].]
The patient was positioned in the dorsal lithotomy position. A [large speculum] was placed. The cervix was visualized and colposcopy was performed with acetic acid and [Lugol's iodine]. The lesion was mapped.
A paracervical block was performed with [X] mL of 1% lidocaine with [1:100,000] epinephrine injected at [4 and 8 o'clock] positions. Additional intracervical injection was performed at [12 and 6 o'clock].
A [large 2.0 × 1.5 cm / medium 1.5 × 1.5 cm / small 1.0 × 1.5 cm] LEEP loop was selected. [A smoke evacuator was used throughout.] A single-pass [/ two-pass (ectocervical + endocervical)] excision was performed at the level of the transformation zone, including a [3–5]-mm margin of normal tissue. The specimen was removed with the loop and placed in formalin with orientation [marker suture at 12 o'clock].
An endocervical curettage (ECC) was performed with a Kevorkian curette. [Adequate / inadequate] material was sent separately.
Hemostasis was achieved with [Monsel's solution / electrocautery / chemical cautery]. [No significant bleeding was encountered.]
None
LEEP specimen with [12 o'clock suture orientation], sent to pathology
Endocervical curetting, sent to pathology separately
Minimal
None
The patient tolerated the procedure well. She was instructed to avoid [intercourse / tampons / swimming] for [4 weeks]. Per ASCCP 2019 risk-based guidelines, post-treatment surveillance was planned: HPV-based test (preferred) or cotesting at 6 months, then at 18 and 30 months, then every 3 years for at least 25 years. Pathology results to guide further management or re-excision if margins are positive.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: HSIL CIN ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: LEEP with ECC
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: Local: paracervical/intracervical block
INDICATIONS: .PTAGE-year-old .PTSEX with HSIL CIN *** on colposcopy biopsy. SCJ ***. Consent obtained.
FINDINGS: Acetowhite lesion ***. SCJ Type *** (fully/not fully visualized). LEEP specimen *** × *** × *** cm. ECC: ***.
PROCEDURE:
Lithotomy. Speculum. Colposcopy with acetic acid/Lugol's; lesion mapped. Paracervical block *** mL lido with epi at 4 + 8 o'clock. Intracervical 12 + 6 o'clock. *** loop selected. Single/two-pass excision at TZ with *** mm normal margin. Specimen in formalin, 12 o'clock suture. ECC with Kevorkian. Hemostasis Monsel's/cautery.
EBL: Minimal
SPECIMENS: LEEP (12 o'clock marked) + ECC to pathology separately
COMPLICATIONS: None
DISPOSITION: Pelvic rest × 4 weeks. Surveillance: HPV-based test at 6 months, then 18 and 30 months, then q3y × 25 years (ASCCP 2019).
Signed: .ME, .MYDEGREE
.TODAYVariants
Cold Knife Cone Biopsy (CKC)
Cold knife cone biopsy was performed rather than LEEP given [concern for microinvasive cancer on prior biopsy / endocervical involvement / desire for clearest possible margins]. A Sturmdorf suture was placed for hemostasis. The cone was excised with a [#15 blade] in a cone-shaped fashion, extending [1.5–2 cm] into the endocervical canal. The depth of excision was [1.5 cm]. The specimen was oriented with [12 o'clock suture / ink]. ECC above the cone was performed. CKC is preferred when margin status is critical for diagnosis of microinvasion or adenocarcinoma in situ.
Charting Tips
- Document LEEP specimen orientation. Pathologists require orientation to map margin involvement. Document that a [12 o'clock] suture or marking ink was applied before removal, and that the specimen was sent labeled with orientation. Unoriented LEEP specimens cannot provide margin information by location.
- Document the type of transformation zone. ASCCP 2019 risk-based guidelines stratify excision vs. ablation eligibility by TZ type: Type 1 (fully ectocervical, fully visible) may allow ablation only if all eligibility criteria are met (no suspicion of invasion or AIS, lesion fully visible and small, no endocervical extension) — however, ASCCP 2019 states excision is preferred over ablation for histologic HSIL (CIN 2 or CIN 3) in the United States. Type 2 (partially endocervical but fully visible) may be eligible for ablation in carefully selected cases. Type 3 (SCJ not fully visualized) requires excision. Document TZ type from colposcopy findings; a Type 3 TZ is absolute documentation of excision necessity.
- Document ECC findings and send separately. The endocervical curettage must be sent as a separate specimen from the LEEP so pathology can assess the endocervical margin independently. Document 'ECC sent separately' in the operative note.
Billing Tips
- 57460 vs 57461 are mutually exclusive — code selection depends on whether the endocervix was removed, not on procedure preference. Bill 57460 (2.76 wRVU, 0-day global) when only the ectocervix/transformation zone is excised without entering the endocervical canal. Bill 57461 (3.34 wRVU, 0-day global) when the endocervical canal is also excised (conization). Document explicitly which tissue was removed; billing 57461 for a purely ectocervical pass is a coding error. Do not bill both 57460 and 57461 at the same session on the same cervix.
- Bill 57520 for cold knife or laser cone biopsy (CKC) performed in the OR (4.01 wRVU, 90-day global). Bill 57522 for loop electrode excision cone (LEEP-cone, 3.58 wRVU, 90-day global) when a more extensive LEEP is performed under anesthesia in the OR. 57522 is not a cold knife code — do not use it for CKC. Both carry a 90-day global vs. 0-day for office LEEP (57461).
- 0-day global for 57461: a separate E/M is billable on the same day if a distinct evaluation is documented. Most LEEP visits include colposcopy, ECC, and LEEP; document each component.
- Endocervical curettage (ECC) performed at the time of LEEP is typically bundled. Do not separately bill ECC in addition to 57461. 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.
General coding reference. Verify with your institution’s billing department before submitting claims.