CPT Code 57500 Excision Procedures on the Cervix Uteri

Precise coding is essential for OBGYN providers to ensure compliance, prevent claim denials, and secure appropriate reimbursement. CPT 57500 is used for diagnostic cervical biopsy, which may include a single or multiple biopsy sites. This procedure is primarily performed to evaluate abnormal Pap smears, HPV positivity, or visually suspicious areas of the cervix.

This guide outlines 2025 coding recommendations, documentation requirements, reimbursement considerations, and modifier use, aligned with AAPC and CMS guidelines, allowing OBGYN practices to code and bill with confidence.

CPT 57500 – Description

Official Definition: “Biopsy of the cervix, single or multiple sites.”

This procedure involves collecting tissue from the cervical epithelium for histopathologic analysis. The physician may use a punch, scalpel, or curette to target specific abnormal areas. CPT 57500 is a diagnostic code and does not include endocervical curettage or loop excision procedures, which are coded separately (CPT codes 57456, 57460, or 57461).

Key distinctions:

• Includes one or more biopsy sites within the cervix.
• Separate codes apply for colposcopy with ECC (57456) or therapeutic loop excision (57460/57461).
• The procedure is typically performed in an office or outpatient setting.

When to Use CPT 57500

CPT 57500 is appropriate when performing a targeted biopsy to evaluate cervical abnormalities. Clinical indications often include:

• Low- or high-grade squamous intraepithelial lesions (LSIL, HSIL).
• Atypical glandular cells (AGC) were detected on cytology.
• Persistent abnormal Pap or positive high-risk HPV tests.
• Visualization of discrete lesions during colposcopy or routine cervical inspection.
• Surveillance of previously treated areas requiring tissue confirmation.

Do not report 57500 if the procedure includes:

• Endocervical curettage (use 57456).
• Loop electrode excision or conization (use 57460/57461).
• Cold-knife conization or larger therapeutic excision (use 57520–57522).

Coding Guidelines and Compliance

Per AAPC and CMS 2025 guidance:

• Report CPT 57500 once per encounter, regardless of the number of biopsy sites.
• The code includes both colposcopic visualization and tissue collection for diagnostic purposes.
• The procedure carries a 10-day global period, encompassing routine post-biopsy visits.
• Documentation must clearly support medical necessity, especially when performed for surveillance or follow-up after prior abnormal results.
• When other unrelated procedures are performed concurrently, verify NCCI edits and apply modifiers only when clinically justified.

Reimbursement Overview

CPT 57500 – 2025 Payment Data

• Global period: 10 days
• Typical setting: Office or outpatient clinic
• Average Medicare reimbursement: $100–$130 (regional variations apply)
• ASC payment: Often bundled with pathology or related procedures

Commercial insurers may require supporting documentation, such as previous Pap results or HPV test outcomes, to establish medical necessity. Pre-authorization may be necessary for certain payers when multiple biopsies are performed.

Modifier Guidance

Accurate modifier use ensures claims are processed correctly:

• Modifier 25: For a significant, separately identifiable E/M service performed the same day.
• Modifier 51: When multiple procedures are performed concurrently.
• Modifier 59 (or XU): To indicate distinct procedural services in addition to unrelated procedures.
• Modifier 26 / TC: Used when separating professional and technical components in facility billing.

Unnecessary modifiers can trigger claim denials or payer audits, so documentation must clearly justify any modifier applied.

Documentation Essentials

Clear, detailed documentation is critical for reimbursement and audit protection. Each cervical biopsy note should include:

• Clinical indication: Abnormal Pap, persistent HPV, or visual lesion.
• Number and location of biopsy sites: Documented precisely for each sample.
• Procedure technique: Instrument used and method of tissue collection.
• Specimen handling: Confirmation that tissue was submitted to pathology.
• Post-procedure follow-up: Instructions and recommended surveillance.

Comprehensive documentation supports the medical necessity of 57500 and ensures audit readiness under CMS 2025 standards.

Example Scenarios

Scenario 1:

A 35-year-old patient with LSIL Pap results undergoes biopsy of a single suspicious area on the cervix. → Report CPT 57500.

Scenario 2:

Multiple abnormal areas are biopsied during colposcopy for high-grade lesions. → Report CPT 57500 (covers single or multiple sites).

Scenario 3:

Loop electrode excision of the transformation zone is performed. → Report CPT 57460 or 57461, not 57500.

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