CPT Code 57455 Colposcopy with Biopsy of Cervix and Upper/Adjacent Vagina

Accurate CPT coding in gynecologic diagnostics is essential for compliance, audit readiness, and proper reimbursement. CPT 57455 is reported when a physician performs a colposcopy of the cervix and upper/adjacent vagina that includes one or more biopsies of the cervix under magnified visualization.

This procedure is commonly performed after an abnormal Pap smear or a positive HPV result to identify and sample areas of dysplasia or neoplasia. The following guide, aligned with AAPC and CMS 2025 updates, provides OBGYN providers with clear direction on code usage, documentation, modifiers, and payer compliance.

CPT 57455 – Description

Official Definition: “Colposcopy of the cervix, including upper/adjacent vagina; with biopsy(s) of the cervix.”

CPT 57455 represents a diagnostic colposcopy performed with one or more targeted cervical biopsies, under magnified visualization, typically following acetic acid or Lugol’s iodine application.

This code differs from:

• 57454: Includes both biopsy and endocervical curettage (ECC).
• 57452: Colposcopy without biopsy.
• 57505: Endocervical curettage alone.

When to Use CPT 57455

Use CPT 57455 when colposcopic inspection identifies lesions that require biopsy of the cervix, with or without assessment of the upper vagina, and ECC is not performed.

Common indications include:

• Abnormal Pap smear results (ASC-US, LSIL, HSIL, AGC, etc.).
• Positive high-risk HPV DNA test.
• Clinically suspicious cervical lesions.
• Follow-up evaluation after prior cervical dysplasia treatment.

Do not report 57455 when:

• ECC is performed in addition to the biopsy (use 57454).
• No biopsy is performed (use 57452).
• A therapeutic excision, such as LEEP or conization, is performed (use 57522).

Coding Guidelines

According to AAPC and CMS 2025 rules, CPT 57455 includes:

• Full colposcopic visualization of the cervix and upper/adjacent vagina.
• One or multiple cervical biopsies (single code per session).
• All related preparatory work and hemostasis.

Do not bill separately for each biopsy site; the code covers all biopsies taken during the same encounter.

The procedure carries a 10-day global period, meaning related post-procedure care within 10 days is bundled under the same CPT code.

When combined with other gynecologic procedures (e.g., vulvar colposcopy or ECC), confirm through NCCI edits whether modifiers are appropriate to unbundle services.

Reimbursement Information

CPT 57455 Reimbursement Overview (2025):

• Global period: 10 days
• Typical site of service: Office or outpatient clinic
• Average Medicare reimbursement: ~$120–$150 (regional variations apply)
• ASC facility payment: Not separately reimbursed unless performed under anesthesia

Commercial payers may require preauthorization if the colposcopy follows a screening result rather than a diagnostic indication. Always verify medical necessity criteria for each payer, especially under updated LCD/NCD coverage policies.

Applicable Modifiers

Appropriate modifiers clarify services and ensure clean claims:

• Modifier 25: For a significant E/M service on the same day.
• Modifier 59 (or XU): For distinct procedural service (e.g., additional vulvar colposcopy).
• Modifier 51: If multiple procedures are performed in one session.
• Modifier 26 / TC: For split billing of professional/technical components when applicable.

Avoid modifier use unless documentation supports a separate and distinct service.

Documentation Requirements

For compliant billing and audit readiness, documentation must clearly include:

• Reason for colposcopy (abnormal Pap, positive HPV, visible lesion, etc.).
• Findings under magnification (acetowhite epithelium, mosaicism, punctation, abnormal vessels).
• Location and number of biopsies taken.
• Type of tissue sampled and specimen labeling.
• Hemostasis method (e.g., silver nitrate, Monsel’s solution).
• Pathology confirmation that specimens were submitted.
• Patient counseling and follow-up plan.

Clear, complete notes are essential for reimbursement and compliance.

Example Scenarios

Scenario 1:

A patient with an LSIL Pap smear undergoes colposcopy. A suspicious lesion is visualized at 6 o’clock on the cervix, and a biopsy is taken. → Report CPT 57455.

Scenario 2:

Colposcopy was performed for HSIL Pap results; three biopsy sites were sampled under visualization, and no ECC was performed. → Report CPT 57455 (one unit only).

Scenario 3:

Colposcopy with biopsy and ECC performed in the same session. → Report CPT 57454 instead of 57455.

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