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CPT 57105: Evaluation and Biopsy of Large Vaginal Lesion

CPT code 57105 represents evaluation and biopsy of a large lesion or cyst on the vaginal mucosa. This diagnostic gynecologic procedure is used to obtain tissue for histopathologic examination when visual or symptomatic findings suggest the need to rule out neoplastic, infectious, or other pathologic processes. Nationally, accurate use of this code supports appropriate clinical documentation, procedure-level reporting, and payment for office- or outpatient-based gynecologic diagnostic care.

Key payers addressed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find guidance on the clinical context for using this code, typical sites of service, common modifiers that may apply, and how this procedure fits into typical gynecologic diagnostic workflows. The publication summarizes benchmarks and payment policy considerations where available and highlights documentation elements that align with national billing and coding expectations. It also provides pointers to related procedural codes and coding scenarios to help clarify when 57105 is the appropriate code to report.

Data not available in the input for detailed payer-specific rates, associated taxonomies, and ICD-10 diagnosis pairings.

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Billing Code Overview

CPT code 57105 describes an encounter in which the provider evaluates a large lesion or cyst on the vaginal mucosa and performs a biopsy. This procedure is a diagnostic surgical service focused on tissue sampling to establish histologic diagnosis.

Service type: Biopsy with evaluation of a large vaginal mucosal lesion or cyst
Typical site of service: Ambulatory surgical center, hospital outpatient department, or office-based gynecologic procedure setting

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CPT 57105: Evaluation and Biopsy of Large Vaginal Lesion

Data not available in the input for detailed payer-specific rates, associated taxonomies, and ICD-10 diagnosis pairings.

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Billing Code Overview

Service type: Biopsy with evaluation of a large vaginal mucosal lesion or cyst
Typical site of service: Ambulatory surgical center, hospital outpatient department, or office-based gynecologic procedure setting

Clinical & Coding Specifications

Clinical Context

A 38-year-old female presents to an outpatient gynecology clinic with a 2-week history of a palpable, enlarging, painless vulvovaginal mass and intermittent spotting. On speculum and bimanual exam the clinician identifies a 2.5 cm fluctuant lesion on the lateral vaginal mucosa suspicious for a Bartholin gland cyst or mucous retention cyst. After counseling on options and obtaining informed consent, the provider prepares for a biopsy to establish tissue diagnosis. The patient is positioned in lithotomy, the lesion is prepped and draped, local anesthetic (e.g., 1% lidocaine with epinephrine) is infiltrated, and the provider excises or incises the lesion and obtains representative tissue for histopathology. Hemostasis is achieved with electrocautery or suture, and the specimen is submitted with appropriate labeling and a pathology requisition. Post-procedure instructions are given and follow-up arranged for pathology review and wound check.

Coding Specifications

Modifier	Description	When to Use
`26`	Professional component	Use when billing only the physician component and technical services were billed separately by another entity.
`52`	Reduced services	Use when the biopsy was partially reduced in scope (for example, limited sampling due to anatomic constraints).
`53`	Discontinued procedure	Use when the procedure was started but stopped for patient safety or unexpected findings before completion.
`59`	Distinct procedural service	Use to indicate a separate and distinct biopsy procedure when other services were performed the same day on a different lesion/site.
`62`	Two surgeons	Use when two surgeons work together as primary surgeons during a complex vaginal lesion procedure.
`66`	Surgical team	Use when a surgical team approach is utilized for a complicated case requiring multiple specialists.
`76`	Repeat procedure by same physician	Use when the same provider performs a repeat biopsy of the vaginal lesion during the global period.
`77`	Repeat procedure by another physician	Use when a different physician repeats the biopsy of the same lesion.
`78`	Unplanned return to the operating room	Use when the patient returns to the OR for a complication related to the initial biopsy (e.g., hemorrhage control) during the global period.
`79`	Unrelated procedure or service by the same physician during the postoperative period	Use when an unrelated procedure is performed during the global period (rare for biopsy coding).

Taxonomy Code	Specialty	Notes
207Q00000X	Obstetrics & Gynecology	Gynecologists commonly perform vaginal lesion evaluation and biopsy.
2080P0208X	Gynecologic Oncology	Gynecologic oncologists perform biopsies when malignancy is suspected or for complex lesions.
207R00000X	Family Medicine	Family physicians with procedural skills may perform office-based vaginal biopsies.
363L00000X	Nurse Practitioner	Women’s health nurse practitioners may perform and bill for vaginal lesion biopsies under appropriate state scope.
363A00000X	Physician Assistant	Physician assistants frequently assist or perform biopsies under supervising physician arrangements.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`N75.0`	Acute Bartholin cyst abscess	Bartholin gland cysts/abscesses present as vulvovaginal masses requiring evaluation and sometimes biopsy to rule out other pathology.
`N75.1`	Chronic or recurrent Bartholin cyst	Chronic lesions may be biopsied if atypical features or failure of standard therapy occur.
`N89.8`	Other specified noninflammatory disorders of vagina	Includes mucosal cysts or benign lesions of the vagina that may need tissue diagnosis.
`R22.2`	Localized swelling, mass and lump, genital region	General symptom code used when a vaginal mass is the presenting problem leading to biopsy.
`C52.9`	Malignant neoplasm of vulva, unspecified	Suspicious or atypical vaginal/vulvar lesions may prompt biopsy to exclude malignancy; use with site-appropriate malignant codes if confirmed.
`N76.0`	Acute vaginitis	Inflammatory conditions may mimic lesions; biopsy is less common but considered when diagnosis is unclear.
`D48.6`	Neoplasm of uncertain behavior of female genital organs	Used when pathology is indeterminate and biopsy is required to characterize the lesion.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`57100`	Excision or destruction of vaginal lesion(s), single or multiple, benign lesions	May be used when the clinician performs excision rather than biopsy or when definitive excision is performed at the same encounter.
`11102`	Tangential biopsy of skin (eg, shave, scoop, saucer), single lesion	Related for superficial mucosal shave-type biopsies when a tangential sampling technique is used on a small vaginal mucosal lesion.
`11104`	Tangential biopsy of skin, 2 to 4 lesions	Use when multiple superficial biopsies of separate vaginal lesions are performed.
`11100`	Biopsy of skin, single lesion (punch)	Analogous when a punch biopsy technique is used on a vaginal mucosal lesion; technique-specific code selection depends on provider preference and payer guidance.
`40490`	Biopsy of lip and oral mucosa; incisional	Included as a procedural analogue for mucosal incisional biopsy technique and specimen handling considerations.

Related Codes

CPT-57100-VAGINAL-MUCOSAL-LESION-BIOPSY

CPT 57100: Biopsy of Lesion on Vaginal Mucosa

CPT-57106-PARTIAL-VAGINECTOMY-UPPER-OR-LOWER-RESECTION

CPT 57106: Partial Vaginectomy, Upper One-Third or Lower Two-Thirds

CPT-57107-PARTIAL-VAGINECTOMY-PARAVAGINAL-TISSUE-RESECTION

CPT 57107: Partial Vaginectomy with Paravaginal Tissue Resection

CPT-57109-VAGINECTOMY-UPPER-HALF-WITH-PELVIC-LYMPHADENECTOMY

CPT 57109: Upper Vaginectomy with Pelvic and Para‑aortic Lymph Node Biopsy

CPT-57110-VAGINECTOMY-COMPLETE-VAGINAL-WALL-REMOVAL

CPT 57110: Complete Removal of Vaginal Wall

CPT-57111-VAGINECTOMY-WITH-PARAVAGINAL-TISSUE-REMOVAL

CPT 57111: Vaginectomy with Paravaginal Tissue Removal

CPT-57120-VAGINAL-CLOSURE-FOR-PROLAPSE

CPT 57120: Vaginal Closure for Vaginal Prolapse

CPT-57130-VAGINAL-TISSUE-FLAP-REMOVAL

CPT 57130: Removal of Vaginal Tissue Flap

CPT-57135-VAGINAL-WALL-CYST-TUMOR-EXCISION

CPT 57135: Excision of Vaginal Wall Cyst or Tumor

References

1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.

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Clinical & Coding Specifications

Clinical Context

Coding Specifications

Modifier	Description	When to Use
`26`	Professional component	Use when billing only the physician component and technical services were billed separately by another entity.
`52`	Reduced services	Use when the biopsy was partially reduced in scope (for example, limited sampling due to anatomic constraints).
`53`	Discontinued procedure	Use when the procedure was started but stopped for patient safety or unexpected findings before completion.
`59`	Distinct procedural service	Use to indicate a separate and distinct biopsy procedure when other services were performed the same day on a different lesion/site.
`62`	Two surgeons	Use when two surgeons work together as primary surgeons during a complex vaginal lesion procedure.
`66`	Surgical team	Use when a surgical team approach is utilized for a complicated case requiring multiple specialists.
`76`	Repeat procedure by same physician	Use when the same provider performs a repeat biopsy of the vaginal lesion during the global period.
`77`	Repeat procedure by another physician	Use when a different physician repeats the biopsy of the same lesion.
`78`	Unplanned return to the operating room	Use when the patient returns to the OR for a complication related to the initial biopsy (e.g., hemorrhage control) during the global period.
`79`	Unrelated procedure or service by the same physician during the postoperative period	Use when an unrelated procedure is performed during the global period (rare for biopsy coding).

Taxonomy Code	Specialty	Notes
207Q00000X	Obstetrics & Gynecology	Gynecologists commonly perform vaginal lesion evaluation and biopsy.
2080P0208X	Gynecologic Oncology	Gynecologic oncologists perform biopsies when malignancy is suspected or for complex lesions.
207R00000X	Family Medicine	Family physicians with procedural skills may perform office-based vaginal biopsies.
363L00000X	Nurse Practitioner	Women’s health nurse practitioners may perform and bill for vaginal lesion biopsies under appropriate state scope.
363A00000X	Physician Assistant	Physician assistants frequently assist or perform biopsies under supervising physician arrangements.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`N75.0`	Acute Bartholin cyst abscess	Bartholin gland cysts/abscesses present as vulvovaginal masses requiring evaluation and sometimes biopsy to rule out other pathology.
`N75.1`	Chronic or recurrent Bartholin cyst	Chronic lesions may be biopsied if atypical features or failure of standard therapy occur.
`N89.8`	Other specified noninflammatory disorders of vagina	Includes mucosal cysts or benign lesions of the vagina that may need tissue diagnosis.
`R22.2`	Localized swelling, mass and lump, genital region	General symptom code used when a vaginal mass is the presenting problem leading to biopsy.
`C52.9`	Malignant neoplasm of vulva, unspecified	Suspicious or atypical vaginal/vulvar lesions may prompt biopsy to exclude malignancy; use with site-appropriate malignant codes if confirmed.
`N76.0`	Acute vaginitis	Inflammatory conditions may mimic lesions; biopsy is less common but considered when diagnosis is unclear.
`D48.6`	Neoplasm of uncertain behavior of female genital organs	Used when pathology is indeterminate and biopsy is required to characterize the lesion.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`57100`	Excision or destruction of vaginal lesion(s), single or multiple, benign lesions	May be used when the clinician performs excision rather than biopsy or when definitive excision is performed at the same encounter.
`11102`	Tangential biopsy of skin (eg, shave, scoop, saucer), single lesion	Related for superficial mucosal shave-type biopsies when a tangential sampling technique is used on a small vaginal mucosal lesion.
`11104`	Tangential biopsy of skin, 2 to 4 lesions	Use when multiple superficial biopsies of separate vaginal lesions are performed.
`11100`	Biopsy of skin, single lesion (punch)	Analogous when a punch biopsy technique is used on a vaginal mucosal lesion; technique-specific code selection depends on provider preference and payer guidance.
`40490`	Biopsy of lip and oral mucosa; incisional	Included as a procedural analogue for mucosal incisional biopsy technique and specimen handling considerations.

Related Codes

CPT-57100-VAGINAL-MUCOSAL-LESION-BIOPSY

CPT 57100: Biopsy of Lesion on Vaginal Mucosa

CPT-57106-PARTIAL-VAGINECTOMY-UPPER-OR-LOWER-RESECTION

CPT 57106: Partial Vaginectomy, Upper One-Third or Lower Two-Thirds

CPT-57107-PARTIAL-VAGINECTOMY-PARAVAGINAL-TISSUE-RESECTION

CPT 57107: Partial Vaginectomy with Paravaginal Tissue Resection

CPT-57109-VAGINECTOMY-UPPER-HALF-WITH-PELVIC-LYMPHADENECTOMY

CPT 57109: Upper Vaginectomy with Pelvic and Para‑aortic Lymph Node Biopsy

CPT-57110-VAGINECTOMY-COMPLETE-VAGINAL-WALL-REMOVAL

CPT 57110: Complete Removal of Vaginal Wall

CPT-57111-VAGINECTOMY-WITH-PARAVAGINAL-TISSUE-REMOVAL

CPT 57111: Vaginectomy with Paravaginal Tissue Removal

CPT-57120-VAGINAL-CLOSURE-FOR-PROLAPSE

CPT 57120: Vaginal Closure for Vaginal Prolapse

CPT-57130-VAGINAL-TISSUE-FLAP-REMOVAL

CPT 57130: Removal of Vaginal Tissue Flap

CPT-57135-VAGINAL-WALL-CYST-TUMOR-EXCISION

CPT 57135: Excision of Vaginal Wall Cyst or Tumor

References

1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.

Published by

Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.