CPT Code 57410 Pelvic Examination Under Anesthesia (Other Than Local) (Manipulation Procedures on the Vagina)

CPT 57410 is defined by the American Medical Association (AMA) as a “Pelvic examination under anesthesia (other than local).”

This code is used when a provider performs a comprehensive pelvic examination while the patient is under general, spinal, or regional anesthesia, allowing for a detailed evaluation that would otherwise be intolerable due to pain, anxiety, or anatomical limitations.

Pelvic exams under anesthesia are often necessary when a standard office exam is not feasible, either because of severe pelvic pain, vaginismus, trauma, or the need for in-depth assessment of pelvic structures such as the uterus, cervix, vagina, and adnexa.

Key Point: CPT 57410 is only reported when the pelvic exam is the sole service performed. If it is part of another surgical or diagnostic procedure, it is considered bundled and not separately billable.

Description of the Procedure

A pelvic examination under anesthesia (PEUA) allows the provider to perform a thorough internal and external evaluation of the pelvic organs without patient discomfort or muscular tension.

Typical steps include:

1. The patient is placed under general or regional anesthesia.
2. The provider performs an external genital inspection.
3. A bimanual and rectovaginal examination is conducted to evaluate the uterus, cervix, ovaries, and adnexa.
4. The provider may also palpate for masses, adhesions, tenderness, or structural abnormalities.
5. Findings are documented in detail, sometimes followed by additional diagnostic procedures such as colposcopy, D&C, or laparoscopy, if indicated.

Because this is performed under anesthesia, it provides greater diagnostic accuracy for pelvic pathology that may not be evident during a standard office exam.

When to Use CPT 57410

Use CPT 57410 when:

• The patient cannot tolerate a standard pelvic exam due to pain, anxiety, or muscular spasm.
• A thorough evaluation is required to assess possible pelvic masses, adhesions, or uterine abnormalities.
• The exam is performed under general or regional anesthesia.
• The procedure is not bundled with another surgical service.

Do not report CPT 57410 when:

• The pelvic exam is performed as part of another surgical or diagnostic procedure (e.g., D&C, hysteroscopy, laparoscopy).
• The exam is done with local anesthesia only.
• The procedure is included in a global surgical package for another service.

Coding and Billing Guidelines

• Global Period: 0 days
• Site of Service: Hospital or Ambulatory Surgical Center (ASC)
• Anesthesia: General, regional, or spinal (not local)
• Bundling Rule: Only separately billable if performed as a stand-alone service
• Medical Necessity: Documentation must justify the need for anesthesia and the diagnostic reason for the exam

Tip: Always link the code with an appropriate ICD-10-CM diagnosis (e.g., severe pelvic pain, abnormal bleeding, suspected mass, or vaginismus) to support medical necessity.

Applicable Modifiers

• Modifier 59 – Distinct Procedural Service: Use only when performed separately from another unrelated procedure during the same encounter.
• Modifier 52 – Reduced Services: If the examination was limited in scope.
• Modifier 22 – Increased Procedural Services: If the exam required extended anesthesia or unusual effort due to complex findings or patient condition.

Documentation Requirements

Strong documentation ensures reimbursement and audit protection. Include:

• Type of anesthesia used (general, spinal, or epidural)
• Reason for performing the exam under anesthesia
• Findings from the pelvic examination
• Extent of the evaluation (vaginal, bimanual, rectovaginal, etc.)
• Confirmation that no other procedures were performed concurrently

Detailed notes explaining why the patient could not tolerate an office exam are essential for payer justification.

Example Clinical Scenarios

Scenario 1 – Pain-Induced Inaccessibility

A 29-year-old patient with severe vaginismus and chronic pelvic pain cannot tolerate an office pelvic exam. The provider performs a pelvic examination under general anesthesia to evaluate uterine position and adnexal tenderness.

Code: CPT 57410

Rationale: Stand-alone pelvic exam performed under anesthesia other than local.

Scenario 2 – Diagnostic Clarification

A 45-year-old with abnormal uterine bleeding and suspected pelvic mass undergoes a pelvic exam under spinal anesthesia to confirm the presence of an adnexal mass before scheduling surgery.

Code: CPT 57410

Rationale: Exam conducted solely under anesthesia for diagnostic evaluation; no concurrent surgical procedure.

Scenario 3 – Trauma Evaluation

A 32-year-old sexual-assault survivor presents with severe pelvic pain and anxiety. The provider performs a pelvic examination under general anesthesia to assess for internal injuries and lacerations.

Code: CPT 57410

Rationale: Full exam under anesthesia for medical evaluation; anesthesia other than local required due to trauma and distress.

Common Coding Challenges

Bundled Procedure Confusion

Many denials occur because CPT 57410 is incorrectly billed with another gynecologic procedure (e.g., hysteroscopy, colposcopy). Remember: it’s separately reportable only when no other service is performed.

Missing Anesthesia Documentation

Claims are frequently denied if the documentation does not specify the type of anesthesia used. The note must clearly state “general” or “regional/spinal anesthesia.”

Lack of Medical Necessity

If the reason for anesthesia is not clinically justified, such as pain intolerance or suspected pathology, payers may deny coverage.

Incorrect Site of Service

This code should not be billed for office-based procedures; it requires a hospital or surgical center setting.

Overlapping Services

If performed immediately before or after another procedure, ensure clear temporal separation and documentation to support use of Modifier 59 if appropriate.

Reimbursement Information

• Average Medicare Reimbursement: ≈ $150 – $250 (region-dependent)
• Global Period: 0 days
• Setting: Hospital outpatient or ASC
• Preauthorization: May be required depending on payer policy

Partner with BillingFreedom for Accurate OBGYN Billing

Procedures like CPT 57410 demand expert understanding of bundling rules, anesthesia documentation, and payer guidelines. At BillingFreedom, our certified medical billing specialists focus exclusively on OBGYN billing and coding, ensuring every claim is compliant, complete, and optimized for reimbursement.

We help OBGYN practices:

• Avoid denials caused by improper bundling or missing documentation.
• Implement payer-specific coding strategies for anesthesia-based procedures.
• Audit claims proactively to identify under-coding or over-coding risks.
• Maximize reimbursements through accurate CPT-ICD linkage and follow-up.

With BillingFreedom, you get more than billing support, you gain a trusted revenue-cycle partner dedicated to helping your practice thrive.

For more details about our exceptional medical billing services, please don't hesitate to contact us via email at info@billingfreedom.com or call us at +1 (855) 415-3472. 

Your financial tranquility is our priority!