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2025 CPT code 57061

Destruction of one or more small or simple vaginal lesions using various methods (laser, electrosurgery, cryosurgery, or chemosurgery).

Follow current CPT coding guidelines and local payer requirements.Accurate documentation is crucial for proper reimbursement.

Modifiers may be applicable depending on the circumstances. For example, modifier -51 (multiple procedures) may be used if multiple lesions are treated. Consult the current CPT and payer guidelines for additional modifier considerations.

Medical necessity is established by the presence of symptomatic or clinically significant vaginal lesions that require treatment. The chosen destruction method must be appropriate for the size, number, and location of the lesions.Documentation must justify the medical necessity of the procedure.

The physician identifies the lesion(s), administers local anesthesia, performs the lesion destruction, and provides post-procedure care instructions. This may involve the use of laser surgery, electrosurgery, cryosurgery, or chemosurgery.

IMPORTANT For extensive lesions, use CPT code 57065.For excision of endometriomas, see codes 49203-49205, 58957, and 58958. If multiple lesions are treated, modifier -51 (multiple procedures) may be applicable.For vulvar lesions, consider codes 56515 (complex) or 56501 (simple).

In simple words: This procedure removes small, simple growths in the vagina. The doctor uses a laser, electric current, freezing, or a special chemical to destroy the growth(s).

This procedure involves the destruction of one or more small or simple vaginal lesions.The patient is placed in the dorsal lithotomy position. A local anesthetic is applied to the vaginal mucosa. The lesion(s) is/are identified and destroyed using one of several methods: laser surgery (vaporizing tissue with a high-intensity light beam), electrosurgery (using a monopolar or bipolar instrument to destroy the lesion), cryosurgery (applying liquid nitrogen with freeze-thaw cycles), or chemosurgery (applying a chemical agent followed by removal of the destroyed tissue). Monopolar or bipolar electrosurgery may be used.

Example 1: A patient presents with a single, small vaginal wart. The physician uses cryosurgery to destroy the lesion., A patient has multiple small condylomata acuminata in the vagina. The physician employs electrosurgery to destroy all lesions., A patient presents with a small, benign polyp in the vagina.The physician utilizes laser surgery to vaporize the polyp.

A complete history and physical examination, including location and size of the lesion(s), method of destruction, and any complications encountered. Operative report detailing the procedure performed, including type of anesthesia, the method used for destroying the lesion, and the number of lesions treated. Pathology report, if a biopsy was taken. Post-operative notes, including any complications or follow-up care instructions provided to the patient.Documentation must support medical necessity.

** This code is used for the destruction of simple lesions. For more extensive lesions, CPT code 57065 should be used.The choice of destruction method will depend on the type and size of the lesion(s).

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