1/22/2007
Fernald Medical Monitoring Program
Physician Exam - Pelvis and Groin Codes
Pelvis and Groin
(Female and Male)
Code
2301
2493
2302
2303
2349
2304
2305
2306
2300
2456
2457
Description
obese (limited by size)
deferred
unable to perform speculum exam because of pain (difficult exam
due to pain)
diffusely tender, pelvic tenderness
suprapubic tenderness
normal exam - for post-hysterectomy
small (speculum), introitus
scar/ unspecified, post surgical change, s/p sx
post-hysterectomy scar - total hysterectomy
s/p conization
s/p cervical cryotherapy
2307
2308
2309
2339
2472
2483
leukoplakia & patchy white lesions
intertriginous rash/ rash where skin folds meet
atrophic vulva
rash on genitalia
condylomata
cystic mass - mons pubis
2310
2311
2416
2417
2467
2312
2463
2313
2314
2446
2481
herpes infection
carcinoma of vulva
vulvar nodules/ cyst
dilated capillaries on vulva
vulvar lesion
Nabothian or retention cysts
Bartholin's gland cyst
trichomonas vaginitis
monilia (candida) vaginitis/ yeast infection
varicostities of labia? Vagina
cyst on labium minora, ext. genitalia
2315
2316
2482
2317
2339
2354
2318
2319
2462
2418
2447
2454
2484
(senile) vaginitis
atrophic vagina
atrophic genitalia (dry)
lesion in episiotomy scar
lesion in vagina
vaginal polyps
growth in vagina at vaginal cuff
vaginal skin tag (remnant)
surgically foreshortened vagina
mild prolapse-vagina
small vaginal opening (stenosed)
foreign latex device in vagina
unusual vaginal odor
Sort Code
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
Code
4366
Description
Erythema - external genitalia (irritation, itch)
2320
2321
2322
2323
2324
2325
2326
brown discharge from cervix/ vaginal
white discharge from cervix/ vaginal
yellow or green discharge from cervix/ vaginal
thick, tan discharge from cervix/ vaginal
(dark) heme cervical discharge/ vaginal
inflammatory discharge vagina/ cervix
clear discharge from cervix/ vaginal
2346
vaginal discharge, unspecified
2327
2328
2329
2414
2330
vaginal mucosa dry and (erythematic)
reddened patches of vaginal/cervical mucosa/cervicitis
vaginal/cervical mucosa bleeds easily
cervical inflammation
(mild) erythema of cervix/ vagina
2331
2332
2333
2334
2335
2336
2494
2415
2419
2337
2338
2353
2427
2428
2429
2445
2492
2440
4336
4352
4387
4392
4386
reddish friable cervical epithelium
cervical ectropion (erosion)
cervical polyp
cancer of cervix
cervical dysplasia
cervix enlarged
cervix removed
cervical scarring
firmness of cervix
abnormal cervix
difficult cervix to examine for PAP
unable to visualize cervix
cervical cyst
cervical nodule
atrophic cervix
uterine tissue extending out of cervix
cervical tenderness
cervical os stenosed, tight
cervical tension
nulliparous os
anterior cervix
posterier cervix
bleeding pap
2340
2341
2342
2343
2344
2460
2461
2362
uterus enlarged
fibrotic uterus
prolapse of uterus
retroversion of uterus
retroflexion of uterus
anteverted uterus
anteflexed uterus
atrophic uterus
1
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
Code
2437
2453
4370
4377
4378
Description
tender uterus
IUD present
nodular uterus
globular uterus
firm uterus
2353
2469
hymenal ring tight
hymen intact
2345
2346
pelvic inflammatory disease
abnormal vaginal/cervical mucosa, reddened patches, bleeds
easily
2347
2348
2363
growth (polyp) in vagina (at vaginal cuff)
lesion in episiotomy scar
pubic nodules
2350
2351
2349
2352
ovaries enlarged
ovarian tumor, cyst
adnexa not well appreciated - DO NOT USE - USE 4402
(firm) mass in adnexal area/ pelvic mass
2355
increase in size of clitoris
2356
2357
left ovary palpable
right ovary palpable
2471
2358
2439
2458
2468
ovary not palpable
adnexal tenderness
(old) blood in vault
spotting blood
sexually underdeveloped (M/F)
2360
2361
bladder prolapse
cystocele
2365
2497
2495
enlarged scrotum without hernia
healing scrotal incision
mass on scrotum/ cyst on scrotum
2368
2369
varicocele
xanthomas on scrotum/ lesion on scrotum
2370
2371
2372
2373
2374
2375
2377
R testes surgically removed (absent)
L testes surgically removed (absent)
R testes undescended
L testes undescended
R testicle smaller than L
L testicle smaller than R
R testicle atrophied
1
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
Code
2378
2442
2486
2443
2366
2367
2376
2499
2379
2438
2364
Description
L testicle atrophied
testes not discernable, palpable
(very) small testicles
enlarged testicles
tender testicle
testes hard; no nodules/ firm
testicular tumor
soft mass on testicle
testicular nodule, cyst
testicular implant-unilateral/bilateral
spermatocele (cystic distension of the epididmsis or testis
containing spermatozoa)
2409
2380
2359
2381
2382
2383
2384
2385
2386
2387
2487
difficult exam of prostate
enlarged prostate
hardened prostate, firtm -> 4309
nodular prostate, prostate nodule
prostatitis
benign prostatic hypertrophy
carcinoma of the prostate
prostate removed surgically
unable to palpate prostate
lower pole/prostate palpable only
assymetric prostate, irregular
4364
2397
4362
4357
4368
4369
4370
4371
4372
4373
4374
4381
4385
4388
4389
4390
4391
4392
4393
4394
4395
4382
4307
4309
4379
unequal testicles descension
hydrocele
groin pain/ tenderness
ridged prostate
blood in ejaculate
urinary sx
nodular uterus
testicular changes
↑ sphincter tone
orcititis
roughness of vaginal wall
urethral discharge
pessiary in place
genital warts
single testicle
prostate post radiation (shrunken)
urgency of stool
posterior cervix
epidiomal swelling/ enlargement
for dyce's spot
buttock pain
boggy prostate
tender prostate
firm prostate
prominent lobes of prostate
1
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
Code
Description
2388
2390
nodule thickening of spermatic cord (2 degrees to vasectomy)
epididymitis
2479
2391
epididymis nodule, cyst
epispadias
2392
phimosis
2493
2393
2394
2395
2396
2397
balanitis (inflammation of the glans penis; assoc with phimosis)
syphilitic chancre
gonorrhea
venereal warts
Peyronie's Disease
hydrocele
2398
2466
2489
urethral discharge
urethral polyps
urethrocele
2399
2389
2408
2475
2408
2492
2400
2401
4343
penile skin lesion
psoriatic scale on penis
small red patch on scrotum
ulcerated skin on penis
penile implant in place
uncircumcised
tenderness R inguinal canal
tenderness L inguinal canal
penile discharge
2402
2403
2404
2405
2406
2407
2451
R inguinal hernia
L inguinal hernia
scrotal hernia
femoral hernia
left inguinal laxity
right inguinal laxity
ventral hernia
2410
2411
2412
4340
4331
4383
stool heme +
stool heme no stool in vault
dark stool
internal henorrhoids
inguinal buldge
2421
2422
2432
2465
external hemorrhoid
inflamed external hemorrhoid
(noninflammed) hemorrhoids
bleeding hemorrhoids
1
194
195
196
197
198
199
200
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
242
Code
2433
2423
2424
2413
2455
2431
2485
Description
decreased sphincter tone
anal fissure
anorectal fistula
anal stenosis - USE 2475
fungal infection-perineum - tinea cruris
anal polyps
perianal rash
2475
anal stenosis - ALSO 2413
2496
2420
2425
deferred rectal exam
no rectum due to previous surgery
prolapse of rectum
2426
2430
2434
2435
2436
2436
2503
4354
4355
4360
rectal tags
rectocele
rectal fibroid
small rectum/tight opening
perirectal decubitus
unusual rectal shape
proctitis
UTI
Painful urnination (dysuria) 4323
rectal nodule
2450
2498
2451
surgical scar
RLQ pain/tenderness
LLQ pain/tenderness
2480
2474
2490
4338
4214
4337
erythematous area/ lesion
ringworm type rash on groin
folliculitis L buttock
incontinence of stool
↓ urinary stream
urinary urgency
2491
varicose veins
2500
catheter
2501
2476
2441
2449
2448
4322
4326
4327
4328
4329
urinary incontinence
sebaceous cyst
well-healed vaginal cuff
part of cervix still present (after hysterectomy)
absent uterus
sebaceous cyst on scrotum
feel uterus through rectal
stenosis of vaginal vault
polyuria
hesitancy w/urination
1
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
270
271
272
273
274
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
290
291
292
Code
4330
4331
4332
2478
4333
2444
2452
2464
2470
2473
2477
2488
4323
4324
4325
Description
painful intercourse
internal hemorrhoid
menstruating
exam limited by stool in rectal vault
perianal skin tag
cervical os open
menorrhagia
impotence, erectile dysfunction
strong urinr odor
cervical muscosa w/petchial
post-hysterectomy scar
dysmenorrhia
dysuria
couldn't assess uterus size
ventral hernia
4414
4413
4347
4348
4349
oligomenorrhea
rectal pain, tenderness, fullnes, rectal changes
PMS
testicular pain
penile lesion
4350
4351
4352
4353
urethral stenosis
amenorrhea
nulliparous os
ABN pelvic exam/ PAP
4312
4313
4314
4315
4316
4317
4318
4319
4320
4321
4300
4301
4302
4303
4305
4306
4307
4308
4309
4310
4311
4400
4401
multiparous cervix
rectal bleeding
irregular menses
previous testicular injury
heavy periods
rectal mass
vaginal itching
sliding hernia
could not visualize cervical os
uterus deviated to the right
dysfunctional uterine bleeding
frequent urination, frequency
hematuria
nocturia
vasectomy
yeast infection/ tinea cruris
tender prostate
labial irritation/ vaginal irritation/ swelling
firm prostate
white cheesy vaginal discharge
mild pelvic relaxation
lesion in vagina
vaginal discharge, unspecified
1
293
294
295
296
297
298
299
300
301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
316
317
318
319
320
321
322
323
324
325
326
327
328
329
330
331
332
333
334
335
336
337
338
339
340
341
342
Code
4402
4403
4404
4405
4406
4407
4408
4409
4410
4411
4312
Description
adnexa not well appreciated/ not palpable
hymenal ring tight
penile implant in place
perirectal decubitus
LLQ pain/tenderness
ulcerated skin on penis
uncircumcised
balanitis-inflammation of the glans penis
catheter
urinary incontinence
proctitis
4212
4215
change in bowel habits
constipation
4415
prostatism
4335
4339
diarrhea/ loose stool
melena (black stool)
4341
4342
4344
4345
4346
hernia
abnormal urine (urinalysis)
mass behind testicle
scrotal enlargement
bladder pain
4356
4359
baginal/ rectal wall thickening
erectile problem
4361
4363
4365
abnormal urinary meatus
(cervical) mucas plug
adnexal fullnes
4367
rectal itching
4334
4375
ovarcectomy
s/p sexual reassignment sx
4376
4380
4384
4358
hard stool
rectal abnormality
vaginal/ vulvar pain
unuable to perform (speculum) exam
1
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357
358
359
360
361
362
363
364
365
366
367
368
369
370
371
372
373
374
375
376
377
378
379
380
381
382
383
384