Frequently Used Codes: Commonly Used ICD-9 Codes
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FREQUENTLY USED CODES Commonly Used ICD-9 Codes in Reproductive Healthcare Female Reproductive Healthcare Breast Conditions 610.0 Solitary cyst of breast 610.1 Fibrocystic change 611.0 Inflam disease of breast 611.2 Fissure of nipple 611.6 Galactorrhea 611.71 Mastodynia 611.72 Lump or mass in breast 611.79 Symptoms in breast NEC 793.80 Abnormal mammogram Cervix 180.0 180.1 180.9 233.1 622.0 622.10 622.11 622.12 622.2 622.7 795.00 795.01 795.02 795.03 795.04 795.05 795.06 795.07 795.08 Endocervical cancer Exocervical cancer Cervical cancer, NOS CIN 3 biopsy Erosion/ectropion cervix Dysplasia, NOS CIN 1 biopsy CIN 2 biopsy Leukoplakia Cervical polyp AGC cytology ASC-US cytology ASC-H cytology LSIL cytology HSIL cytology High risk HPV-DNA positive Cytologic evidence of malignancy Lacking transformation zone Unsatisfactory cytology Early Pregnancy 630 Hydatidiform mole 631 Blighted ovum 632 Missed abortion 633.10 Tubal pregnancy 634.91 Incomplete SAB 634.92 Complete SAB 635.90 Therapeutic abortion (TAB) 640.00 Threatened SAB Endometriosis 617.0 Adenomyosis 617.3 Pelvic endometriosis 617.6 Endometriosis in scar 617.9 Endometriosis NOS Gyn Endocrine 704.1 Hirsuitism 256.31 Premature menopause 256.4 PCOS 278.00 Obesity, unspecified 278.01 Obesity, morbid 278.02 Overweight 307.50 Eating Disorder, unspecified Infertility 628.0 Infertility-anovulation 628.1 Infertility-pituitary origin 628.2 Infertility-tubal origin 628.3 Infertility-uterine origin 628.4 Infertility-cervical origin 628.9 Female infertility, NOS Urinary Tract 595.1 Interstitial cystitis 597.81 Urethral syndrome 625.6 Stress incontinence 788.30 Urinary incontinence, unspecified 788.31 Urge incontinence 788.33 Mixed incontinence Menopause 627.0 Perimenopausal menorrhagia 627.1 Postmenopausal bleeding 627.2 Menopausal syndrome 627.3 Atrophic vaginitis 627.4 Symptoms w artificial menopause 627.9 Menopausal disorder NOS Vagina 623.0 Dysplasia of vagina (VaIN) 623.3 Tight hymenal ring 623.5 Noninfectious leukorrhea 623.6 Vaginal hematoma 623.8 Vaginal cyst 623.9 Noninflammatory disorder, NOS Menstrual Disorders 625.4 Premenstrual syndrome 626.0 Amenorrhea 626.1 Oligomenorrhea 626.2 Menorrhagia 626.3 Pubertal menorrhagia 626.4 Irregular menstruation 626.5 Intermenstrual bleeding 626.6 Metrorrhagia 626.7 Postcoital bleeding 626.9 Menstrual disorder, NOS Vulva 184.4 221.2 233.32 624.01 624.02 624.5 624.6 624.9 698.3 701.0 Ovary and Adnexa 182.3 Ovarian cancer 620.0 Follicular cyst of ovary 620.1 Corpus luteum cyst 620.2 Ovarian cyst, NOS 620.5 Torsion of ovary or tube 620.9 Noninflam. disorder ovary, NOS Male Reproductive Healthcare Pain Syndromes 789.04 Abdominal pain, LLQ 789.05 Abdominal pain, RLQ 789.09 Abdominal pain, bilateral 625.0 Dyspareunia 625.1 Vaginismus 625.2 Mittelschmerz 625.3 Dysmenorrhea 625.70 Vulvodynia, NOS 625.71 Vulvar vestibulitis 625.9 Pelvic pain 788.7 Uterus 182.0 218.9 621.0 621.30 621.4 621.5 621.6 621.9 Endometrial cancer Uterine myoma Endometrial polyp Endometrial hyperplasia Hematometra Asherman’s syndrome Malposition of uterus Disorder of uterus, NOS Page 1 099.40 569.49 604.90 607.9 608.9 Vulvar neoplasm, malignant Vulvar neoplasm, benign VIN 3 VIN I VIN 2 Hematoma of vulva Polyp of labia and vulva Noninflam dis vulva, NOS Squamous cell hyperplasia (LSC) Lichen sclerosus (LS) Nonspecific urethritis (NGU) Proctitis (anus/rectum) Epididymitis: unspecified Disorder of penis: unspecified Scrotal pain (disorder of male genital organs, unspecified) Urethral discharge Contraceptive Complications V 26.51 V 26.52 V 45.51 V 45.52 996.30 Tubal ligation status Vasectomy status Presence of IUD Presence of implant Mechanical complication of implant 996.32 Mechanical comp IUD 996.65 Infection due to IUD General Complications 780.2: Syncope (vasovagal) 995.27 Drug allergy or hypersensitivity 998.11 Hemorrhage complicating procedure 998.59 Post-operative infection Key: See Page 4 Commonly Used ICD-9 Codes in Reproductive Healthcare (cont.) Infectious Conditions Cervicitis 616.0 Cervicitis Chlamydia 099.41 Urethritis 099.50 Unspecified site 099.51 Pharynx 099.52 Proctitis (anus/rectum) 099.53 Cervicitis 099.56 Perihepatitis Ectoparasites 132.2 Pediculosis (crab lice) 133.0 Scabies Genital Herpes 054.10 Genital herpes, unspecified 054.11 Herpetic vulvovaginitis 054.12 Herpetic ulceration of vulva 054.13 Herpetic ulceration of penis 054.19 Other site HSV 569.41 Ulcer of anus, rectum Genital Warts 078.0 Molluscum contagiosum 078.10 Viral warts, NOS 078.11 Condyloma acuminatum 079.4 HPV infection, unspecified site Gonorrhea 098.0 Urethritis 098.11 Cystitis 098.12 Prostatitis 098.13 Epididymitis-orchitis 098.15 Cervicitis 098.16 Endometritis 098.17 Salpingitis 098.19 Other 098.6 Pharynx 098.7 Proctitis (anus/rectum) Pelvic Inflammatory Disease (PID) 614.0 Acute PID 614.1 Chronic PID 614.2 PID, not specified 614.4 Tubo-ovarian abscess 614.5 Acute pelvic peritonitis 614.6 Post-PID pelvic adhesions 615.0 Acute endometritis 615.1 Chronic endometritis Syphilis 091.0 Primary genital (chancre) 091.3 Secondary syphilis 092.9 Early syphilis, latent unspecified 094.0 Neurosyphilis 096.0 Late syphilis, latent 097.0 Late syphilis, unspecified 097.1 Latent syphilis, unspecified Urinary Tract Infection 590.80 Pyelonephritis 595.0 Acute cystitis 599.7 Hematuria 788.1 Dysuria 788.41 Urinary frequency Vaginal Infection 112.1 Candidal vulvovaginitis 131.01 Trichomonal vulvovaginitis 616.10 Bacterial vaginosis Vulvar Infection & Inflammation 110.3 Tinea cruris 616.10 Vulvitis, NOS 616.2 Bartholin duct cyst 616.3 Bartholin duct abscess 616.4 Abscess of vulva, other site 616.50 Ulcer of vulva, NOS Contraception (cont.) V 25.03 Encounter for emergency cont. V 25.04 Natural FP to avoid pregnancy V 25.2 Sterilization procedure V 25.8 Post-vasectomy sperm count V 25.09 Contraceptive advice only Miscellaneous V 04.89 Prophylactic vaccination V 26.41 Natural FP to achieve pregnancy V 26.49 Procreative mgmt-counseling: preconception care visit V 41.7 Sexual function problem Pregnancy Evaluation V 72.40 Preg test/exam - not confirmed V 72.41 Pregnancy test/exam, negative V 72.42 Pregnancy test/exam, positive Preventive Medicine Visits V 70.0 General medical examination V 72.31 Gynecologic examination V 76.19 Screening breast exam Sexually Transmitted Infection V 01.6 Contact with or exposure to STD V 02.8 Carrier/suspected carrier of STD V 12.09 Personal history of STD V 65.40 Counseling NOS V 65.44 HIV counseling V Codes V 65.45 Counseling on other STDs Cervical Cytology V 65.5 Worried well V 10.41 History of cervical cancer V 69.2 High risk sexual behavior V 13.2 History of abnormal Pap V 73.81 HPV screening V 15.89 High risk for cervical cancer V 73.88 Chlamydia screening V 67.01 Vaginal Pap after hyst for cancer V 73.89 Screen for viral disease (HSV) V 72.32 Pap to confirm recent normal Pap V 74.5 Screening for bacterial STDs (GC) after abnormal Pap V 76.2 Screening Pap smear cervix Contraception V 25.01 Prescribe oral contraceptives V 25.41 Surveillance of OC user V 25.9 Contraceptive management, NOS: Initiate patch, ring, or DMPA V 25.40 Contraceptive surveillance nos: patch, ring, DMPA V 25.5 Implant insertion V 25.43 Implant removal or surveillance V 25.11 Insertion of IUD V 25.12 Removal of IUD V 25.13 Removal + insertion of IUD V 25.42 IUD surveillance V 25.02 Initiate barrier method V 25.49 Surveillance: barrier method Key: See Page 4 Page 2 Commonly Used CPT Codes in Reproductive Healthcare Cervix 57452 57454 57455 57456 57460 57461 57500 57505 57511 57513 57520 57522 57800 Colpo, no biopsy Colpo, biopsy + ECC Colpo, biopsy only Colpo, ECC only Colpo + LEEP Colpo + LEEP cone Cervical biopsy only ECC only Cryotherapy Laser ablation Knife or laser cone biopsy LEEP only Dilation of canal Contraception 57170 Diaphragm, cap fitting 58300 Insert IUD 58301 Remove IUD 11976 Remove LNG implant 11981 Insert implant 11982 Remove implant 11983 Remove+insert implant Genital Wart Treatment 46900 Anal (<14), chemical 46916 Anal (<14), cryosurgery 46922 Anal (<14), surgical excision 46924 Anal (>15), any method 54050 Penile (<14), chemical 54056 Penile (<14), cryosurgery 54056 Penile (<14), cryosurgery 54060 Penile (<14), surgical excision 54065 Penile (>15), any method 56501 Vulva (<14), any method 56515 Vulva (>15), any method 57061 Vaginal (<14), any method 57065 Vaginal (>15), any method Office Lab 87205 Gram stain 87210 Saline/KOH microscopy 83986 Vaginal pH 81000 Urinalysis, dip+ micro 81002 Urine dip only 81025 Pregnancy test, urine Other CPT Codes 96372 Office injection, therapeutic HPV-4 vaccine 90460 Vaccine administration through HPV-2 vaccine age 18 Inject MPA for contraceptive use 9046 Each additional vaccine Intrauterine copper contraceptive component Levonogesterol releasing IUC 90471 Vaccine administration, 19 and Contraceptive supply, ring older Contraceptive supply, patch 90472 Each additional vaccine component Etonogestrel implant system, including implant and supplies 99000 Conveyance of specimen from J0696 Injection, ceftriaxone office to lab J1050 Injection, DMPA, 1mg 36415 Collection of venous blood by Other dispensed rx: check with payer venipuncture Drugs 90649 90650 J1055 J7300 J7302 J7303 J7304 J7307 Pregnancy 59200 Insert osmotic dilator 59812 Suction/incompl SAB 59820 Suction/ missed SAB 59830 Suction/ septic SAB Ultrasound 76830 Transvaginal, non-OB 76857 Abd’l, limited, non-OB 76817 Transvaginal, preg 76801 Abdominal, preg <14 weeks 76805 Abdominal, preg, >14 weeks Uterus 58100 Endometrial biopsy Vagina 57100 57105 57160 57420 57421 Biopsy, simple Biopsy, require suture Pessary fitting Colposcopy vagina Colposcopy with biopsy(s) Vulva 56405 56420 56605 56606 56820 56821 I&D abscess I&D Bartholin abscess Biopsy, single Biopsy, multiple Colposcopy vulva Colposcopy with biopsy(s) __________________________________________________________________________________________________________ Commonly Used Evaluation and Management (E/M) Codes Preventive Medicine Office Visits New Estab Patient Age 99384 99394 12-17 yo 99385 99395 18-39 yo 99386 99396 40–64 yo 99387 99397 > 65 yo Problem-Oriented Office Visits See page 4. Other E/M Codes 99024 Post-op visit (surgical global) 99401 Preventative counseling 99441 Telephone E/M by clinician, estab pt, 5 -10 mins 99442 Telephone E/M by clinician, estab pt, 11-20 mins 99443 Telephone E/M by clinician, estab pt, 21-30 mins Modifiers -21 Prolonged E/M services -24 Unrelated E/M service by same clinician during surgical global period -25 Significant, separately identifiable E/M service by same clinician on same day of procedure/other service -51 Multiple procedures (similar operation, same body area) -52 Reduced services -53 Discontinued procedure Key: See Page 4 Page 3 Commonly Used Evaluation and Management (E/M) Codes (cont.) Problem-Oriented Office Visits New Patient Established Patient 3 Key Components Method HISTORY EXAM MDM FTF time Typical mins (range) Straight10 (≤ 15) forward Straight99202 EPF EPF 20 (16-25) forward 99203 Detailed Detailed Low 30 (26-37) 99204 Comp Comp Mod. 45 (38-53) 99205 Comp Comp High 60 (>53) Level: All 3 must meet or exceed requirements 99201 PF 3 Key Components Method Time Method HISTORY 99211 PF Minimal EXAM MDM Minimal Minimal Time Method FTF time Typical mins (range) 5 (≤ 7) Straight10 (8-12) forward 99213 EPF EPF Low 15 (13-20) 99214 Detailed Detailed Mod. 25 (21-33) 99215 Comp. Comp. High 40 (>33) Level: Two of three must meet or exceed requirements 99212 PF PF Three Key Component Tables History Level History Table for New Patient HPI ROS # elements # systems PFSH # areas History Level History Table for Established Patient HPI ROS PFSH # elements # systems # areas PF Brief 1-3 elements N/A N/A Minimal N/A N/A N/A EPF Brief 1-3 elements Problem Pertinent (1 sys) N/A PF Brief 1-3 elements N/A N/A Detailed Extended 4+ elements Extended (2-9 sys) Pertinent Any 1 of 3 Extended Complete 4+ elements (10-14 sys) Choose level of lowest scoring subcomponent. Comp. Complete -All 3 Physical Exam Table Exam Level Single Organ Exam Elements PF 1-5 bullets EPF ≥ 6 bullets Detailed ≥ 12 bullets Comprehensive Female genitourinary exam + other organs Choose level based on number of bullets. Key Comp Estab EPF FTF HPI Mod NEC NOS PF PFSH ROS Comprehensive Established Expanded problem-focused Face-to-face History of present illness Moderate Not elsewhere classified Not otherwise specified Problem-focused Patient, family, social history Review of Systems Problem Pertinent (1 sys) Extended Extended Detailed 4+ elements (2-9 sys) Extended Complete Comp. 4+ elements (10-14 sys) Choose level of lowest scoring subcomponent. EPF Brief 1-3 elements N/A Pertinent Any 1 of 3 Complete -Any 2 of 3 Medical Decision Making Table Number of Data amt and Risk of MDM Level dx/mgmt complexity complications options StraightMinimal Minimal Minimal forward 1 point 1 point Limited Limited Low Low 2 points 2 points Multiple Multiple Moderate Moderate 3 points 3 points Extensive Extensive High High 4+ points 4+ points Two 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 2013 Professional Edition and 2013 AMA ICD-9-CM for the most current codes. The National Training Center for Management and Systems Improvement is not responsible for any rejected claims. Last updated: September 2013 Page 4
