Q&A: CPT coding for cervical mapping during colposcopy

Q: When might it be appropriate to report computer-aided mapping of the cervix uteri using 2021 CPT add-on code 57465 (computer-aided mapping of cervix uteri during colposcopy, including optical dynamic spectral imaging and algorithmic quantification of the acetowhitening effect)?

A: Effective January 1, coders may report CPT add-on code 57465 for mapping of cervix uteri during colposcopy. This add-on code may be appended to colposcopy CPT codes 57420-57421, 57452, 57454-57456, and 57460-57461.

Cervical mapping is a separately identifiable service performed by a physician during a colposcopy examination. A colposcopy is the usage of a scope to view and evaluate issues on and within the cervix.  Cervical mapping technology draws attention to any additional areas of the cervix that may need further examination, according to the American College of Obstetricians and Gynecologists.

Notably, this technology allows both the physician and the patient to view diagnostic images of the cervix. The adjunctive map and electronic documentation allow for more detailed diagnosis and earlier identification of current and potential cervical issues.

Editor’s note: Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, ICD-10-CM/PCS, ambassador/trainer and an E/M, and procedure-based coding, compliance, data charge entry, and HIPAA privacy specialist in Melba, Idaho, answered this question during the HCPro webinar, 2020 ICD-10-CM/CPT Reporting for Obstetrical Services. She can be reached at webbservices.lori@gmail.com or http://lori-lynnescodingcoachblog.blogspot.com. 

This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.