LEEP (Loop Electrosurgical Excision Procedure) / Cervical Cone Biopsy

CPT 57461
Approach Endoscopic
Add-on / Variant CPTs
  • 57460 — Colposcopy with loop electrode biopsy of cervix
  • 57520 — Conization of cervix, with or without fulguration, with or without dilatation and curettage, with or without repair; cold knife or laser
Preoperative Diagnosis:

Cervical high-grade squamous intraepithelial lesion (HSIL / CIN 2-3), confirmed on colposcopy-directed biopsy

Postoperative Diagnosis:

Same

Procedure Performed:

LEEP (loop electrosurgical excision procedure) [/ cold knife cone biopsy] with endocervical curettage

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Nurse/tech name]

Anesthesia:

Local: [X] mL 1% lidocaine with 1:100,000 epinephrine [paracervical block and intracervical injection]

Indications:

The patient is a [age]-year-old [female] with HSIL [CIN 2 / CIN 3] confirmed on colposcopy-directed biopsy. The transformation zone was [completely / not completely] visualized. LEEP was recommended for excisional treatment. The risks, benefits, and alternatives including ablation and observation were discussed and informed consent was obtained.

Findings:

Colposcopy with acetic acid application demonstrated [acetowhite lesion / mosaic / punctation] extending to the [3 and 9 o'clock positions / entire circumference] of the ectocervix, involving the [ectocervix / endocervix]. The squamocolumnar junction was [fully visualized (Type 1) / not fully visualized (Type 3)]. The LEEP specimen measured [X × X × X] cm. [Endocervical curettage demonstrated [insufficient / positive] material.]

Description of Procedure:

The patient was positioned in the dorsal lithotomy position. A [large speculum] was placed. The cervix was visualized and colposcopy was performed with acetic acid and [Lugol's iodine]. The lesion was mapped.

A paracervical block was performed with [X] mL of 1% lidocaine with [1:100,000] epinephrine injected at [4 and 8 o'clock] positions. Additional intracervical injection was performed at [12 and 6 o'clock].

A [large 2.0 × 1.5 cm / medium 1.5 × 1.5 cm / small 1.0 × 1.5 cm] LEEP loop was selected. [A smoke evacuator was used throughout.] A single-pass [/ two-pass (ectocervical + endocervical)] excision was performed at the level of the transformation zone, including a [3–5]-mm margin of normal tissue. The specimen was removed with the loop and placed in formalin with orientation [marker suture at 12 o'clock].

An endocervical curettage (ECC) was performed with a Kevorkian curette. [Adequate / inadequate] material was sent separately.

Hemostasis was achieved with [Monsel's solution / electrocautery / chemical cautery]. [No significant bleeding was encountered.]

Complications:

None

Specimens:

LEEP specimen with [12 o'clock suture orientation], sent to pathology
Endocervical curetting, sent to pathology separately

Estimated Blood Loss:

Minimal

Drains:

None

Disposition:

The patient tolerated the procedure well. She was instructed to avoid [intercourse / tampons / swimming] for [4 weeks]. Post-procedure follow-up was planned for [4–6 months] with [co-test (Pap + HPV)]. Pathology results to guide surveillance or further management.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: HSIL CIN ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: LEEP with ECC
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: Local: paracervical/intracervical block

INDICATIONS: .PTAGE-year-old .PTSEX with HSIL CIN *** on colposcopy biopsy. SCJ ***. Consent obtained.

FINDINGS: Acetowhite lesion ***. SCJ Type *** (fully/not fully visualized). LEEP specimen *** × *** × *** cm. ECC: ***.

PROCEDURE:
Lithotomy. Speculum. Colposcopy with acetic acid/Lugol's — lesion mapped. Paracervical block *** mL lido with epi at 4 + 8 o'clock. Intracervical 12 + 6 o'clock. *** loop selected. Single/two-pass excision at TZ with *** mm normal margin. Specimen in formalin, 12 o'clock suture. ECC with Kevorkian. Hemostasis Monsel's/cautery.

EBL: Minimal
SPECIMENS: LEEP (12 o'clock marked) + ECC to pathology separately
COMPLICATIONS: None
DISPOSITION: Pelvic rest × 4 weeks. Follow-up co-test 4–6 months.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Cold Knife Cone Biopsy (CKC)

Cold knife cone biopsy was performed rather than LEEP given [concern for microinvasive cancer on prior biopsy / endocervical involvement / desire for clearest possible margins]. A Sturmdorf suture was placed for hemostasis. The cone was excised with a [#15 blade] in a cone-shaped fashion, extending [1.5–2 cm] into the endocervical canal. The depth of excision was [1.5 cm]. The specimen was oriented with [12 o'clock suture / ink]. ECC above the cone was performed. CKC is preferred when margin status is critical for diagnosis of microinvasion or adenocarcinoma in situ.

Charting Tips
  • Document LEEP specimen orientation. Pathologists require orientation to map margin involvement. Document that a [12 o'clock] suture or marking ink was applied before removal, and that the specimen was sent labeled with orientation. Unoriented LEEP specimens cannot provide margin information by location.
  • Document the type of transformation zone. ASCCP guidelines stratify management by TZ type. Type 1 (fully visible) allows ablation; Type 3 (not visible) requires excision. Document TZ type from colposcopy findings to justify LEEP over ablation.
  • Document ECC findings and send separately. The endocervical curettage must be sent as a separate specimen from the LEEP so pathology can assess the endocervical margin independently. Document 'ECC sent separately' in the operative note.
Billing Tips
  • Bill 57461 for loop electrosurgical excision procedure (LEEP) with colposcopy (3.34 wRVU, 0-day global). This is the standard code for outpatient LEEP for CIN.
  • Bill 57522 for cold knife conization of cervix (3.58 wRVU, 90-day global). Use when cervical cone biopsy is performed in the OR under anesthesia. Note the 90-day global period vs. 0-day for LEEP.
  • 0-day global for 57461: a separate E/M is billable on the same day if a distinct evaluation is documented. Most LEEP visits include colposcopy, ECC, and LEEP; document each component.
  • Endocervical curettage (ECC) performed at the time of LEEP is typically bundled. Do not separately bill ECC in addition to 57461. Document ECC performed as part of the procedure note.
  • Repeat LEEP for positive margins is a new billable procedure, not within any global period of the first LEEP. Document the pathology result that indicated re-excision.