LEEP (Loop Electrosurgical Excision Procedure) / Cervical Cone Biopsy
Cervical high-grade squamous intraepithelial lesion (HSIL / CIN 2-3), confirmed on colposcopy-directed biopsy
Same
LEEP (loop electrosurgical excision procedure) [/ cold knife cone biopsy] with endocervical curettage
[***, MD/DO]
[Nurse/tech name]
Local: [X] mL 1% lidocaine with 1:100,000 epinephrine [paracervical block and intracervical injection]
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.
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 was [negative for dysplasia / positive for HSIL / nondiagnostic (insufficient tissue)].]
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.]
None
LEEP specimen with [12 o'clock suture orientation], sent to pathology
Endocervical curetting, sent to pathology separately
Minimal
None
The patient tolerated the procedure well. She was instructed to avoid [intercourse / tampons / swimming] for [4 weeks]. Per ASCCP 2019 risk-based guidelines, post-treatment surveillance was planned: HPV-based test (preferred) or cotesting at 6 months, then at 18 and 30 months, then every 3 years for at least 25 years. Pathology results to guide further management or re-excision if margins are positive.
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. Surveillance: HPV-based test at 6 months, then 18 and 30 months, then q3y × 25 years (ASCCP 2019).
Signed: .ME, .MYDEGREE
.TODAYVariants
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 2019 risk-based guidelines stratify excision vs. ablation eligibility by TZ type: Type 1 (fully ectocervical, fully visible) may allow ablation only if all eligibility criteria are met (no suspicion of invasion or AIS, lesion fully visible and small, no endocervical extension) — however, ASCCP 2019 states excision is preferred over ablation for histologic HSIL (CIN 2 or CIN 3) in the United States. Type 2 (partially endocervical but fully visible) may be eligible for ablation in carefully selected cases. Type 3 (SCJ not fully visualized) requires excision. Document TZ type from colposcopy findings; a Type 3 TZ is absolute documentation of excision necessity.
- 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.
Documentation & Reimbursement Considerations
- Report LEEP (Loop Electrosurgical Excision Procedure) / Cervical Cone Biopsy as the primary service when it is the definitive operation performed.
- Both carry a 90-day global vs.
- 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 the primary service. 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.