WIXLIB

FREQUENTLY USED CODESCommonly Used ICD-10 Codes in Reproductive Healthcare (cont’d)Infectious ied siteA56.19A56.3Proctitis (anus/rectum)PharynxA56.4A56.8Chlamydial infection of other sitesNon-specific is (crab lice)B85.3B86ScabiesGenital HerpesHerpesviral infection of urogenitalA60.00system, unspecifiedHerpetic ulceration of penisA60.01Herpesviral infection of other maleA60.02genital organsA60.03Herpesviral cervicitisHerpetic vulvovaginitisA60.04Herpesviral infection of otherA60.09urogenital tractHerpesviral infection of perianal skinA60.1and rectumAnogenital herpesviral infection,A60.9unspecifiedUlcer of anus, rectumK62.6Genital WartsA63.0Anogenital (venereal) wartsB07.9Viral warts, NOSB08.1Molluscum contagiosumHPV infection, unspecified siteB97.7Gonorrhea (GC)GC infection of lower genitourinaryA54.00tract, unspecifiedA54.01Cystitis and urethritis, unspecifiedA54.02GC vulvovaginitis, NOSA54.03GC cervicitis, unspecifiedOther GC infection of lowerA54.09genitourinary tractGC infection of lower genitourinaryA54.1tract w/ periurethral & accessorygland abscessA54.21Infection of kidney and ureterA54.22ProstatitisGC infection of other male genitalA54.23organsGC female PIDA54.24A54.29Other GC genitourinary infectionsA54.29Other GC genitourinary infectionA54.5Gonococcal pharyngitisProctitis (anus/rectum)A54.6Pelvic Inflammatory Disease (PID)N70.11Chronic salpingitisN70.12Chronic oophoritisN70.13Chronic salpingitis and oophoritisN70.91Salpingitis, unspecifiedN70.92Oophoritis, unspecifiedN70.93Salpingitis and oophoritis, unspec.N71.0Acute inflamm. disease of uterusN71.1Uterus: chronic inflamm. diseaseN73.0Acute parametritis & pelvic cellulitisN73.1Chronic parametritis & pelvicN73.2Unspec. parametritis & pelviccellulitiscellulitisPID (Cont’d)N73.3Female acute pelvic peritonitisN73.6Female pelvic peritoneal adhesions(postinfective)SyphilisA51.0Primary genital syphilisA51.31 Condyloma latumA51.39 Other secondary syphilis of skinA51.5Early syphilis, latentA52.11 Tabes dorsalisA52.16 Charcôt's arthropathy (tabetic)Urinary Tract InfectionN11.9Chronic tubulo-interstitial nephritis,Tubulo-interstitialnephritis, notN12unspecifiedspecified as acute or chronicN13.6PyonephrosisN30.00 Acute cystitis without hematuriaN30.01 Acute cystitis with hematuriaR30.0DysuriaR30.9Painful micturition, unspecifiedR31.9Hematuria, unspecifiedR35.0Frequency of micturitionVaginal InfectionA59.01 Trichomonal vulvovaginitisB37.3Candidiasis of vulva and vaginaN76.0 Acute vaginitisN76.1 Subacute and chronic vaginitisN76.2 Acute vulvitisN76.3 Subacute and chronic vulvitisVulvar Infection & InflammationTinea crurisB35.6N75.0Cyst of Bartholin's glandN75.1Abscess of Bartholin's glandN75.8Other diseases of Bartholin's glandN76.0Acute vaginitisN76.1Subacute and chronic vaginitisN76.2Acute vulvitisN76.3Subacute and chronic vulvitisN76.4Abscess of vulvaN76.6Ulceration of vulvaFormer V codesCervical CytologyPap to confirm recent normal PapZ01.42after abnormal PapZ08Vaginal Pap after hyst for cancerZ12.4Screening Pap smear cervixZ85.41History of cervical cancerZ87.42History of abnormal cytology/otherabnormal diseases of genital tractContraceptionZ30.011 Prescribe oral contraceptivesZ30.012 Encounter for emergency cont.Z30.013 Initial Rx of injectable contraceptiveZ30.014 Initial Rx of IUDZ30.018 Initial Rx of other contraceptivesZ30.019 Initial Rx of contraceptives, NOSZ30.02 Natural FP to avoid pregnancyZ30.09 Other contraception counselingZ30.2Sterilization procedureZ30.40Contraceptive surveillance NOSZ30.41Surveillance of OC userZ30.42Surveillance of injectable cont.Z30.430 Insertion of IUDPage 3Contraception (Cont’d)Z30.431 IUD surveillanceZ30.432 Removal of IUDZ30.433 Removal reinsertion of IUDZ30.49Surveillance of other contraceptivesZ30.8Other contraceptive managementZ30.9Contraceptive management, NOSZ97.5Presence of (intrauterine) deviceZ98.51 Tubal ligation statusZ98.52 Vasectomy statusMiscellaneousZ23(Prophylactic) vaccinationZ31.61 Natural FP to achieve pregnancyZ31.69 Procreative mgmt. - counseling:preconception careF52.9Sexual func. Problem-no psych cond.Pregnancy EvaluationZ32.00 Pregnancy test/exam - not confirmedZ32.01 Pregnancy test/exam, positiveZ32.02 Pregnancy test/exam, negativePreventive Medicine VisitsZ00.00 General adult medical exam w/oabnormal findingsZ00.01 General adult medical exam w/abnormal findingsZ01.411 Gyn. Exam w/ abnormal findingsZ01.419 Gyn. exam w/o abnormal findingsZ12.39 Screening breast examProcreative ManagementZ31.41Fertility testing (semen analysis)Testing of female genetic diseaseZ31.430carrierstatus testing of femaleZ31.438Other geneticTesting of male for genetic diseaseZ31.440Z31.448carrierstatus testing of maleOther geneticZ31.5Genetic counselingProcreative counseling /advice usingZ31.61natural family planningZ31.69Preconception care (otherprocreative managementZ31.81Encounter for male factor infertilityZ31.82Encounterfor Rh incompatibilityinfemale patientZ31.89Other procreative managementstatusUnspecified procreative mgmt.Z31.9Z98.51Tubal ligation statusZ98.52Vasectomy statusSexually Transmitted InfectionZ11.3Screening for bacterial STDs (GC)Z11.4Screening for HIVZ11.51 HPV screeningZ11.59 Screening for other viral diseasesZ11.8Chlamydia screeningZ20.2Contact with or exposure to STIZ22.4Carrier/suspected carrier of STIWorried, wellZ71.1Z71.7HIV counselingZ71.89 Counseling on other STDsZ71.9Counseling NOSZ72.51 High risk heterosexual behaviorZ72.52 High risk homosexual behaviorZ72.53 High risk bisexual behaviorZ86.19 Personal history of STI

Commonly Used Current Procedural Terminology (CPT)Codes in Reproductive 0575055751157513575205752257800Colpo, no biopsyColpo, biopsy ECCColpo, biopsy onlyColpo, ECC onlyColpo LEEPColpo LEEP coneCervical biopsy onlyECC onlyCryotherapyLaser ablationKnife or laser cone biopsyLEEP onlyDilation of canalContraception57170 Diaphragm, cap fitting58300 Insert IUD58301 Remove IUD11976 Remove LNG implant11981 Insert implant11982 Remove implant11983 Remove insert implantGenital Wart Treatment46900 Anal ( 14), chemical46916 Anal ( 14), cryosurgery46922 Anal ( 14), surgical excision46924 Anal ( 15), any method54050 Penile ( 14), chemical54056 Penile ( 14), cryosurgery54056 Penile ( 14), cryosurgery54060 Penile ( 14), surgical excision54065 Penile ( 15), any method56501 Vulva ( 14), any method56515 Vulva ( 15), any method57061 Vaginal ( 14), any method57065 Vaginal ( 15), any methodOffice Lab87205 Gram stain87210 Saline/KOH microscopy83986 Vaginal pH81000 Urinalysis, dip micro81002 Urine dip only81025 Pregnancy test, urineOther CPT Codes96372 Office injection, therapeutic90460 Vaccine administration throughHPV-4 vaccineage 18HPV-2 vaccineEach additional vaccineInject MPA for contraceptive use 9046componentIntrauterine copper contraceptive90471 Vaccine administration, 19 andLevonogesterol releasing IUColderContraceptive supply, ring90472 Each additional vaccineContraceptive supply, patchcomponentEtonogestrel implant system,99000 Conveyance of specimen fromincluding implant and suppliesoffice to labJ0696 Injection, ceftriaxone36415 Collection of venous blood byJ1050 Injection, DMPA, 1mgvenipunctureOther dispensed rx: check with Pregnancy59200 Insert osmotic dilator59812 Suction/incompl SAB59820 Suction/ missed SAB59830 Suction/ septic SABUltrasound76830 Transvaginal, non-OB76857 Abd’l, limited, non-OB76817 Transvaginal, preg76801 Abdominal, preg 14 weeks76805 Abdominal, preg, 14 weeksUterus58100 Endometrial biopsyVagina5710057105571605742057421Biopsy, simpleBiopsy, require suturePessary fittingColposcopy vaginaColposcopy with biopsy(s)Vulva564055642056605566065682056821I&D abscessI&D Bartholin abscessBiopsy, singleBiopsy, multipleColposcopy vulvaColposcopy with biopsy(s)Commonly Used Evaluation and Management (E/M) CodesPreventive Medicine Office VisitsNewEstabPatient Age99384 9939412-17 yo99385 9939518-39 yo40–64 yo99386 9939699387 99397 65 yoProblem-Oriented Office VisitsSee page 5.Other E/M Codes99024 Post-op visit (surgical global)99401 Preventative counseling99441 Telephone E/M by clinician,estab pt, 5 -10 mins99442 Telephone E/M by clinician,estab pt, 11-20 mins99443 Telephone E/M by clinician,estab pt, 21-30 minsModifiers-21 Prolonged E/M services-24 Unrelated E/M service by sameclinician during surgical globalperiod-25 Significant, separately identifiableE/M service by same clinician onsame day of procedure/otherservice-51 Multiple procedures (similaroperation, same body area)-52 Reduced services-53 Discontinued procedureKey: See Page 5Page 4

Commonly Used Evaluation and Management (E/M) Codes(cont.)Problem-Oriented Office VisitsNew Patient3 Key aightforwardStraightforwardLowMod.HighEstablished Patient3 Key ComponentsMethodTime MethodFTF timeTypical mins (range)HISTORYEXAMMDMTime MethodFTF timeTypical mins (range)10 ( 15)99211MinimalMinimalMinimal5 ( 7)20 (16-25)99212PFPF10 (8-12)30 (26-37)45 (38-53)60 ( StraightforwardLowMod.HighLevel: All 3 must meet or exceed requirements15 (13-20)25 (21-33)40 ( 33)Level: Two of three must meet or exceed requirementsThree Key Component TablesHistoryLevelHistory Table for New PatientHPIROS# elements# systemsPFSH# areasHistoryLevelHistory Table for Established PatientHPIROSPFSH# elements# systems# areasPFBrief1-3 elementsN/AN/AMinimalN/AN/AN/AEPFBrief1-3 elementsProblemPertinent(1 sys)N/APFBrief1-3 elementsN/AN/ADetailedExtended4 elementsExtended(2-9 sys)PertinentAny 1 of 3EPFExtendedCompleteComplete-All 34 elements(10-14 sys)Choose level of lowest scoring subcomponent.Comp.Exam LevelPFEPFDetailedComprehensivePhysical Exam TableSingle Organ Exam Elements1-5 bullets 6 bullets 12 bulletsFemale genitourinary exam other organsChoose level based on number of prehensiveEstablishedExpanded problem-focusedFace-to-faceHistory of present illnessModerateNot elsewhere classifiedNot otherwise specifiedProblem-focusedPatient, family, social historyReview of SystemsProblemPertinent(1 sys)ExtendedExtendedDetailed4 elements(2-9 sys)ExtendedCompleteComp.4 elements(10-14 sys)Choose level of lowest scoring subcomponent.MDM LevelStraightforwardLowModerateHighBrief1-3 elementsN/APertinentAny 1 of 3Complete-Any 2 of 3Medical Decision Making TableNumber ofData amt andRisk malMinimal1 point1 pointLimitedLimitedLow2 points2 pointsMultipleMultipleModerate3 points3 pointsExtensiveExtensiveHigh4 points4 pointsTwo of three elements must be met or exceeded.This list is for informational purposes only. Always refer to the most recent version of the CPT 2015 Professional Edition and 2015 AMA ICD-10-CM for the most currentcodes. The National Training Center for Management and Systems Improvement is not responsible for any rejected claims.Note: Funding for this resource was made possible by the Office of Population Affairs (Grant FPTPA006023-01-00). The views expressed in written materials or publications do not necessarily reflect the official policies of theDepartment of Health and Human Services, nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.Page 5

Commonly Used ICD-10 Codes in Reproductive Healthcare (cont'd) Male Reproductive Healthcare A63.0 Penile lesion E29.1 Testicular hypofunction F52.0 Hypoactive sexual desire disorder F52.21 Male erectile disorder F52.4 Premature ejaculation F52.8 Other sexual dysfunction, not related to substance use N52.32 ED following radical cystectomy