What is CPT Code 57454?

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What is CPT Code 57454?

Did you know that around 662,000 new cases of cervical cancer are diagnosed annually worldwide—and more than 348,000 women die from it? The numbers are alarming, and early detection is crucial.

One of the most important tools for identifying pre-cancerous or high-risk cervical changes is colposcopy. But while the clinical role of this procedure is vital, accurate and timely billing is equally important to ensure providers are reimbursed appropriately.

This guide focuses on one of the most commonly used codes in cervical colposcopy billing—CPT code 57454. Read on to understand its description, clinical use cases, modifiers, and essential documentation requirements.

What Does CPT Code 57454 Actually Cover?

CPT code 57454 describes a colposcopic examination of the cervix and the adjacent upper vagina with cervical biopsy and endocervical curettage (ECC).

A colposcope—a lighted magnifying tool—allows providers to get a detailed, close-up view of the cervix, vagina, and vulva to identify abnormal or precancerous tissue.

When Should CPT Code 57454 Be Used?

Here are some real-world scenarios that show when CPT 57454 is the appropriate code:

Is This Code Used for High-Grade ASC-H Follow-Up?

Yes.
Example: A 33-year-old patient with an ASC-H Pap result undergoes colposcopy. The provider identifies high-grade aceto-white changes extending into the endocervical canal. Directed biopsies and ECC are performed.

Outcome: CPT 57454 is correctly reported.

What if the Patient Has Persistent LSIL?

Example: A 27-year-old patient with LSIL for over 19 months undergoes colposcopy. A faint aceto-white lesion is visualized. One biopsy is taken, followed by a sharp ECC due to suspected canal involvement.

Outcome: CPT 57454 applies.

Does CPT 57454 Apply When Invasive Cancer Is Suspected?

Yes.
Example: A 58-year-old postmenopausal patient presents with post-coital bleeding. Colposcopy reveals a suspicious, potentially invasive lesion. Multiple biopsies and ECC are performed.

Outcome: CPT 57454 should be billed.

Which Modifiers Should You Use With CPT Code 57454?

Proper modifier usage is essential for clean claims.

Modifier 22 – When Extra Work Is Required

If the provider must perform significant additional work—such as extensive cervical dilation—to complete the procedure, append modifier 22 to indicate increased procedural complexity.

Common Error to Avoid:
Do not bill code 57800 (cervical dilation) separately. It is permanently bundled with 57454 under CCI edits.

What Are the Billing & Bundling Rules for CPT 57454?

Because 57454 is a bundled code, you cannot separately bill for services that are already included in it.

Codes You Cannot Report on the Same Date of Service

  • 57452 – Colposcopy only
  • 57455 – Colposcopy with cervical biopsy
  • 57456 – Colposcopy with ECC (no biopsy)
  • 57505 – ECC only

Submitting these together will result in denials due to bundling rules.

What Documentation Is Required to Prevent Denials?

Thorough documentation is essential. Your operative notes must clearly support medical necessity and confirm that all three components were performed:

  1. Colposcopy
  2. Cervical biopsy
  3. Endocervical curettage (ECC)

Here’s what to include:

Medical Necessity Documentation—What Needs to Be Written?

  • Specific clinical reason for the procedure
  • ICD-10 codes linked appropriately to CPT 57454
  • Findings that prompted the colposcopy (e.g., AGC, HSIL, abnormal bleeding)
  • Confirmation of patient consent, risks, and expected discomfort

Colposcopy Documentation—What Must Be Detailed?

  • Statement confirming colposcope use
  • Whether visualization was satisfactory or unsatisfactory
  • Transformation zone type (TZ 1, 2, or 3)
  • Use of acetic acid or other agents
  • Description of abnormal findings (e.g., mosaicism, aceto-white changes)
  • Specific location of the most suspicious lesion

Cervical Biopsy Documentation—What Should Be Included?

  • Number of biopsies taken
  • Exact locations of each biopsy
  • Method of bleeding control
  • Confirmation that specimens were sent to pathology

Endocervical Curettage Documentation—How Should It Be Recorded?

Because ECC is required for CPT 57454, documentation must state:

  • That ECC was performed
  • Instrument used (brush, curette, etc.)
  • Why ECC was clinically necessary

Why Is Accurate Coding for 57454 So Important?

Incorrect documentation or code selection can lead to:

  • Claim denials
  • Delayed payments
  • Revenue cycle disruptions
  • Compliance issues

Following proper guidelines prevents avoidable revenue loss.

Summary

CPT code 57454 represents a bundled service that includes:

  • Cervical colposcopy
  • Cervical biopsy
  • Endocervical curettage

You cannot bill codes 57452, 57455, 57456, or 57505 on the same day. If substantial additional work (like extensive dilation) is performed, append modifier 22—but do not bill 57800 separately.

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