2025 CPT code 57410
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Female Genital System Surgery Feed
Pelvic examination under anesthesia (other than local).
Modifiers 22, 47, 51, 52, 53, 58, 59, 73, 74, 76, 77, 78, 79, 99, AQ, AR, CR, ET, GA, GC, GJ, GR, KX, PD, Q5, Q6, QJ, XE, XP, XS, XU may apply depending on the specific circumstances of the procedure. Consult the official CPT codebook for the most up-to-date information on modifier usage.
Medical necessity for this procedure is established when a thorough pelvic examination is required under anesthesia to properly evaluate pelvic organs and their relationship to surrounding structures. This may be needed for preoperative assessment, for diagnosing conditions like pelvic pain or abnormal bleeding, or for post-operative evaluations to assess for any complications.
The provider is responsible for administering anesthesia (other than local), positioning the patient, performing the examination (including speculum insertion and bimanual palpation), and collecting any specimens as clinically indicated.
In simple words: This medical code describes a pelvic exam done while the patient is asleep under anesthesia (not a local numbing injection). The doctor examines the vagina, cervix, and other pelvic organs.A Pap smear might also be taken.
This CPT code encompasses a pelvic examination conducted under general or regional anesthesia, excluding local anesthesia.The procedure involves a comprehensive examination of the external and internal female genitalia. This may include the use of a speculum for vaginal and cervical visualization and a bimanual examination to assess pelvic organ size and identify any abnormalities.A Pap smear may be collected if clinically indicated. The patient is positioned in the dorsal lithotomy position.
Example 1: A patient is scheduled for a hysterectomy.A pelvic exam under anesthesia is performed preoperatively to assess the size and position of the uterus and other pelvic organs, guiding the surgical approach., A patient presents with pelvic pain and abnormal bleeding. A pelvic exam under anesthesia is performed to facilitate a thorough evaluation of the internal organs and identify the source of the symptoms., A patient undergoes a laparoscopic procedure. A pelvic examination under anesthesia is done after the procedure to evaluate the surgical site and ensure there are no complications.
Complete medical history, including presenting complaints and relevant past medical history.Documentation of the examination findings, including any abnormalities detected. If a Pap smear is collected, documentation of the collection and results. Anesthesia record. Operative notes (if performed within the context of a surgical procedure).
** In the context of teaching hospitals, explicit consent from the patient is crucial for any pelvic examination performed by a student or trainee, even under anesthesia.Violation of this consent requirement may have significant legal and ethical repercussions.
- Revenue Code: P6C (MINOR PROCEDURES - OTHER)
- Payment Status: Active
- Specialties:Obstetrics and Gynecology, Urogynecology, General Surgery
- Place of Service:Office, Ambulatory Surgical Center, Inpatient Hospital, Hospital Outpatient Department