CPT Code 57456 Endoscopy Procedures on the Cervix Uteri

Accurate CPT coding is essential for OBGYN providers to ensure compliance, minimize denials, and secure timely reimbursement. CPT 57456 represents a colposcopic examination of the cervix and upper/adjacent vagina, followed by endocervical curettage (ECC) - a procedure in which tissue samples are collected from the endocervical canal for histologic review.

This diagnostic procedure is often performed when a Pap smear or HPV test reveals abnormalities or when the transformation zone of the cervix is not fully visible. Proper documentation and coding, as outlined in AAPC and CMS 2025 guidelines, are critical to ensure accurate claim submission and audit readiness.

CPT 57456 – Description

Official Definition: “Colposcopy of the cervix, including upper/adjacent vagina; with endocervical curettage.”

In this procedure, a colposcope (a magnifying optical instrument) is used to carefully examine the cervix and adjacent vaginal walls for any abnormalities. After visual inspection, the provider performs endocervical curettage, using a curette or cytobrush to gently scrape tissue from inside the endocervical canal for microscopic evaluation.

It’s important to note that CPT 57456 does not include a cervical biopsy. If both a cervical biopsy and ECC are performed during the same encounter, you should instead report CPT 57454. Similarly, if only colposcopic visualization is done without sampling, report 57452.

This distinction ensures that the correct code reflects the extent of the diagnostic procedure performed, which is crucial for payer compliance.

When to Report CPT 57456

CPT 57456 should be billed when an ECC is performed as part of a diagnostic colposcopy, particularly when endocervical tissue evaluation is clinically necessary.

Common indications include:

• Abnormal Pap smear findings (ASC-US, LSIL, HSIL, AGC).
• Positive high-risk HPV testing.
• Unsatisfactory visualization of the transformation zone.
• Follow-up evaluation after cervical procedures such as LEEP, cryotherapy, or cone biopsy.
• Investigation of suspected glandular or endocervical lesions.

This code ensures appropriate reporting when the endocervical canal must be sampled for diagnostic purposes. It should not be used for:

• Colposcopy without any tissue sampling (57452).
• Colposcopy with cervical biopsy (57455).
• Therapeutic excision procedures (57520 or 57522).

By selecting the correct CPT, providers demonstrate adherence to medical necessity and coding accuracy, which supports both clinical documentation and compliance audits.

Coding and Compliance Guidelines For CPT 57456

Under CMS 2025 and AAPC standards, CPT 57456 encompasses both colposcopic visualization and endocervical curettage as a single, bundled service.

You should report this code only once per encounter, even if multiple curettage passes are made. The code carries a 10-day global period, meaning routine post-procedure visits within that period are included in the global package and not separately billable.

Do not report CPT 57505 (endocervical curettage alone) in conjunction with CPT 57456, as they are already bundled. If additional gynecologic procedures are performed during the same session, always review NCCI edits before applying modifiers to avoid unintentional code overlap.

For surveillance cases (e.g., post-treatment ECC), ensure that medical necessity is documented clearly in the clinical note. Many payers now require justification if the procedure follows a prior excisional treatment or repeat Pap test rather than an initial abnormal finding.

CPT 57456 Reimbursement Overview

The reimbursement for CPT 57456 varies based on location and payer policy.

According to the 2025 Medicare Physician Fee Schedule, the procedure typically includes a 10-day global period and is performed in an office or outpatient setting.

• Average Medicare reimbursement: Approximately $120–$145 (regional variations apply).
• Ambulatory Surgical Center (ASC) payment: Often bundled when performed with other services.
• Commercial payers: May require preauthorization or supporting documentation for coverage.

Accurate coding, appropriate modifier use, and detailed documentation help prevent delays or denials related to medical necessity verification.

Appropriate Modifier Use For CPT 57456

Modifiers should be applied carefully and only when supported by the documentation. Incorrect or unnecessary modifiers are a common cause of payer denials.

• Modifier 25: Use when a significant, separately identifiable E/M service is performed on the same day as the procedure.
• Modifier 51: Apply if multiple procedures are performed during the same encounter.
• Modifier 59 (or XU): Use to denote distinct procedural services, if performed in conjunction with unrelated gynecologic work.
• Modifier 26 / TC: Use when separating professional and technical components in hospital billing.

Each modifier should have a specific clinical justification in the medical record to ensure compliance and avoid post-payment review issues.

Documentation Requirements

Accurate, detailed documentation is essential for accurate reimbursement and compliance with audit standards. The procedure note for CPT 57456 should include:

• Clinical indication: Reason for performing ECC (abnormal Pap, HPV positivity, or unsatisfactory colposcopy).
• Colposcopic findings: Description of cervical surface, transformation zone visibility, and any observed abnormalities.
• Details of ECC: Instrument used (curette or brush), number of passes, and tissue collection details.
• Specimen handling: Confirmation that tissue samples were submitted for pathology.
• Post-procedure care: Instructions, patient education, and follow-up plan.

Comprehensive notes not only ensure proper payment but also protect the provider in case of payer audits or chart reviews.

Example Scenarios

Scenario 1:

A 29-year-old patient with an ASC-US Pap result undergoes colposcopy. The transformation zone cannot be visualized, and the physician performs ECC to sample endocervical tissue. → Report CPT 57456.

Scenario 2:

During colposcopy, both a cervical biopsy and ECC are performed. → Use CPT 57454, as it includes both services.

Scenario 3:

A physician performs ECC without colposcopy due to a prior hysterectomy or cervical stenosis. → Report CPT 57505.

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