Ch. 13 Female Reproductive System

Question 1

A patient presents in her 15 th week of pregnancy with cramping, cervix dilated to 2 cm and bulging amniotic sac. The physician confirms a threatened abortion and decides to manage the patient expectantly with monitoring. What is the ICD-10-CM code?

Answer 1

a. O20.0, Z3A.15
Response Feedback:
Rationale: In the ICD-10-CM Alphabetic Index look for Abortion/threatened (spontaneous) O20.0. Chapter notes indicate to code the weeks of gestation. In the Alphabetic Index look for Pregnancy/weeks of gestation/15 weeks referring you to Z3A.15. Verify codes in the Tabular List.

Question 2

Mrs. Jones, G1P0, is diagnosed with polyhydramnios and is scheduled for amniocentesis to aspirate some of the excessive fluid from the amniotic sac. The amniocentesis is performed under ultrasound guidance. What is/are the code(s) for the procedure performed?

Answer 2

a. 59001
Response Feedback:
Rationale: In the CPT® Index look for Amniocentesis/Therapeutic/Amniotic Fluid Reduction directing you to code 59001. Read the parentheses in the code descriptor; this code includes the ultrasound guidance. The ultrasound guidance is not separately reported. 59000 is for diagnostic amniocentesis.

Question 3

Patient has TAH-BSO. What CPT® code is reported?

Answer 3

c. 58150
Response Feedback:
Rationale: TAH-BSO stands for Total Abdominal Hysterectomy – Bilateral Salpingo-oophorectomy. In the CPT® Index look for Hysterectomy/Abdominal/Total, directing you to 58150, 58200, 58956. A bilateral salpingo-oophorectomy is the removal of the tubes and ovaries. CPT® code 58150 includes with or without removal of the tubes and ovaries.

Question 4

What ICD-10-CM code is reported for VIN III?

Answer 4

d. D07.1
Response Feedback:
Rationale: Look in the ICD-10-CM Alphabetic Index for VIN – See Neoplasia, intraepithelial, vulva. Look in the Alphabetic Index for Neoplasia/vulva/grade III (severe dysplasia) referring you to D07.1. Verify in the Tabular List. The Alphabetic Index listing for Dysplasia/vulva/severe NEC also directs you to D07.1. VIN III is listed as carcinoma in situ in the Tabular List.

Question 5

Patient with genital warts has cryotherapy of an extensive number of lesions on her mons pubis, labia and perineum. How is this procedure coded?

Answer 5

a. 56515
Response Feedback:
Rationale: The mons pubis and labia are part of the vulva. In the CPT® Index look for Destruction/Lesion/Vulva/Extensive and you are referred to 56515. The extensive code is reported due to the extensive number of lesions. Verify the code in the numeric section.

Question 6

What ICD-10-CM code is reported for an incomplete uterine prolapse?

Answer 6

d. N81.2
Response Feedback:
Rationale: In the ICD-10-CM Alphabetic Index look for Prolapse/uterus/incomplete directing you to code N81.2. Looking in the Tabular List confirms this code selection.

Question 7

A patient is seen for three extra visits during the third trimester of her 30-week pregnancy because of her history of pre-eclampsia during her previous pregnancy which puts her at risk for a recurrence of the problem during this pregnancy. No problems develop. What diagnosis code(s) is/are reported for these three extra visits?

Answer 7

b.
O09.893, Z3A.30

Response Feedback:
Rationale: Because the patient had pre-eclampsia in her previous pregnancy she is being monitored for three additional visits because she is at a high risk of getting pre-eclampsia during this current pregnancy. Due to the patient being high-risk, she will not be coming in for supervision of a normal pregnancy, eliminating Z34.83. Code O14.03 is incorrect because she is just being monitored for possible pre-eclampsia. O09.893 is used for supervision of pregnancy of other high risk. Look in the ICD-10-CM Alphabetic Index for Pregnancy/supervision of/high-risk/due to (history of)/specified NEC directing you to O09.89-. In the Tabular List a 7 th character is needed to indicate the trimester. Report code O09.893 for the third trimester. Instructional note in the beginning of Chapter 15 indicates a code from Z3A is reported with the pregnancy codes. The weeks of pregnancy is 30 weeks. Look in the Alphabetic Index for Pregnancy/weeks of gestation/30 weeks and you are directed to Z3A.30. Verify in the Tabular List.

Question 8

If a physician obtains a Pap smear specimen from a non-Medicare patient and incurs the cost for it to be transferred to an outside laboratory. How is this coded?

Answer 8

b. 99000
Response Feedback:
Rationale: Look to the CPT® Index for Specimen Handling and you are directed to 99000, 99001. CPT® code 99000 is reported when the physician incurs cost for collection, handling and/or conveyance of a specimen for transfer from the office to a laboratory. This is a non-Medicare patient, the HCPCS Level II code Q0091 is only reported for a Medicare patient.

Question 9

A 23 year-old woman presents with sudden LLQ (left lower quadrant) pain which does not resolve. The decision is made to perform exploratory laparoscopy revealing a cyst on the left ovary. The cyst is removed along with a partial oophorectomy. What is/are the CPT® code(s) reported for this procedure?

Answer 9

a. 58661
Response Feedback:
Rationale: Even though the patient started with a diagnostic (exploratory) laparoscopy it turned into a surgical laparoscopy. You cannot bill both procedures separately. Diagnostic laparoscopy is always included in a surgical laparoscopy. There was removal of the left ovary (partial oophorectomy) with the cyst. In the CPT® Index, look for Ovary/Laparoscopy directing you to codes 58660-58662, 58679. Reviewing the codes, 58661 is the correct code for the partial oophorectomy.

Question 10

What modifier is appropriate for a separately billable antenatal service during the global OB package period?

Answer 10

c. No modifier is needed
Response Feedback:
Rationale: An antenatal service is performed before the baby is delivered. According to the notes in the Maternity Care and Delivery subsection in the CPT® codebook “Antepartum care includes the initial prenatal history and physical examinations; recording of weight, blood pressures, fetal heart tones, routine chemical urinalysis, and monthly visits up to 28 weeks gestation; biweekly visits to 36 weeks gestation; and weekly visits until delivery.”

Question 11

A pregnant patient presents to the hospital in active labor. The obstetrician providing her prenatal care is contacted to perform the delivery. The provider delivers twins vaginally. The obstetrician will also provide the postnatal care. What CPT® code(s) describe this procedure?

Answer 11

c. 59400, 59409-51
Response Feedback:
Rationale: The delivery is vaginal. Look in the CPT® Index for Vaginal Delivery directing you to codes 59400, 59610-59614. As the physician has provided the prenatal care and will provide the postpartum care, the vaginal delivery for twin A is the global service described by 59400. The delivery of twin B is coded with 59409 with modifier 51 appended indicating this is a multiple procedure. Prenatal and postpartum care applies to the total care of the patient and not to both deliveries.

Question 12

Ultrasound indicates a 20-week fetus has a distended bladder and the decision is made to perform vesicocentesis. The procedure is successful and the bladder is emptied. What CPT® is code reported for this procedure?

Answer 12

c. 59074
Response Feedback:
Rationale: In the CPT® Index look for Fetal Procedure/Fluid Drainage directing you to 59074. Verify in the numeric section.

Question 13

Patient presents with no menses and positive pregnancy test but ultrasound finds no uterine contents. Embryo has implanted on left ovary and this is treated with laparoscopic oophorectomy. What are the CPT® and ICD-10-CM codes reported for this procedure? Do not code the ultrasound.

Answer 13

d.
59151, O00.202

Response Feedback:
Rationale: When an embryo implants on the ovary, it is an ectopic (ovarian) pregnancy. In the CPT® Index look for Ectopic Pregnancy/Laparoscopy with Salpingectomy and/or Oophorectomy and you are referred to 59151.

For the diagnosis, look in the ICD-10-CM Alphabetic Index for Pregnancy/ovarian and you are directed to O00.20. Locate the code in the Tabular List. A sixth character is needed for laterality. Sixth character 2 is used for left ovary.

Question 14

Patient has a LEEP conization for CIN II. What are the CPT® and ICD-10-CM codes reported for this procedure?

Answer 14

a. 57522, N87.1
Response Feedback:
Rationale: In the CPT® Index, look for Conization/Cervix directing you to codes 57461, 57520, 57522. Code 57461 is LEEP performed with a colposcopy, but a colposcopy was not performed in this case. LEEP stands for loop electrode excision procedure and is reported with CPT® code 57522.

In the ICD-10-CM Alphabetic Index look for CIN, which directs you to see Neoplasia, intraepithelial, cervix. Look for Neoplasia/intraepithelial/cervix/grade II directing you to code N87.1. Tabular List confirms CIN II is coded N87.1. Moderate dysplasia of cervix is another name for CIN II.

Question 15

Patient wishes permanent sterilization and elects laparoscopic tubal ligation with Falope ring. What is the CPT® code reported for this service?

Answer 15

a. 58671
Response Feedback:
Rationale: Patient is having a laparoscopic tubal ligation; her fallopian tubes (oviducts) are surgically blocked off (occlusion) with a Falope rings to prevent pregnancy (permanent sterilization). In the CPT® Index, look for Laparoscopy/Ovary/Oviduct/Oviduct Surgery, which guides you to codes 58670, 58671, 58679. Review the codes and 58671 is the correct code for the procedure performed.

Question 16

A patient presents with cervical cancer; it has spread and metastasized throughout the pelvic area. She receives a total abdominal hysterectomy with bilateral salpingo-oophorectomy, cystectomy and creation of an ileal conduit and partial colectomy. What is/are the CPT® code(s) reported for this service?

Answer 16

b.
58240

Response Feedback:
Rationale: Due to the cervical cancer with metastasis to the pelvic area (gynecological malignancy) the procedure performed is a pelvic exenteration. This is a total hysterectomy with removal of ovaries and fallopian tubes (salpingo-oophorectomy). This includes the removal of her bladder (cystectomy) with creation of a passageway to drain the kidneys through an opening on the abdomen (ileal conduit) and partial removal of the large bowel or colon (resection of the rectum and colon). In the CPT® Index look for Exenteration/Pelvis directing you to 45126, 51597, 58240. 45126 is used for colorectal malignancy. 51597 is used for vesical, prostatic or urethral malignancy. Code 58420 is the only code needed and includes all procedures performed.

Question 17

A patient with uterine prolapse presents for laparoscopic hysterectomy and colpopexy. After induction of general anesthesia, the laparoscope is introduced into the abdomen with separate placement of ports for visualization. The surgeon began to tie off the uterine artery when the patient had a sudden drop in blood pressure and could not be stabilized. The procedure was discontinued. No procedures were completed. What are the CPT® and modifier code(s) for this service?

Answer 17

b. 58570-53
Response Feedback:
Rationale: After general anesthesia was initiated and the surgery for the laparoscopic hysterectomy began, the patient’s blood pressure dropped and could not be stabilized. There are two ways to find the code for a laparoscopic hysterectomy. Start by looking in the CPT® Index for Hysterectomy/Laparoscopic/Total or Laparoscopy/Hysterectomy/Total. Both refer you to 58570-58573. 58570 is correct for the laparoscopic hysterectomy. Modifier 53 is the correct modifier to append because there was a threat to the well-being of the patient during the surgery. You do not code for the colpopexy (57425) because the colpopexy surgery had not begun.

Question 18

A patient with severe adenomyosis has a vaginal hysterectomy with bilateral salpingo-oophorectomy. After the uterus is removed it is weighed at 300 grams. What is the CPT® code reported for this procedure?

Answer 18

b. 58291
Response Feedback:
Rationale: A vaginal hysterectomy code can be selected based on the weight of the uterus and additional procedures included with the hysterectomy. In the CPT® Index look for Hysterectomy/Vaginal/Removal Tubes/Ovaries directing you to codes 58262, 58263, 58291, 58292, 58552, 58554. A vaginal hysterectomy for a uterus greater than 250 grams is reported from code range 58290-58294. Further selection of removal of tubes and ovaries defines code 58291.

Question 19

A patient has ovarian cancer of both ovaries. She has removal of her ovaries with peritoneal washings and assessment of the abdomen for any metastases, including inspection of omentum, diaphragm and multiple biopsies. Lymph nodes in the pelvic and peri-aortic areas were also biopsied. She has previously had a hysterectomy. What are the CPT® and ICD-10-CM codes reported for this service?

Answer 19

c.
58943, C56.1, C56.2

Response Feedback:
Rationale: Patient has ovarian cancer in which there was an open approach for removal of her ovaries only (total bilateral oophorectomy) along with biopsies performed on the peritoneal, pelvic and peri-aortic lymph nodes. Look in the CPT® Index for Ovary/Excision/Total guiding you to codes 58940-58943. 58943 is correct and includes the oophorectomy for malignancy and the biopsies. This is used for with or without salpingectomy and with or without omentectomy.

To report the diagnosis, ovarian cancer, look in the ICD-10-CM Table of Neoplasms for Neoplasm, neoplastic/ovary/Malignant Primary column referring you to C56.-. In the Tabular List a 4 th character is reported for laterality. Both ovaries are cancerous so you must report C56.1 and C56.2.

Question 20

A patient with a long history of endometriosis has an open surgical approach to perform an exploratory laparotomy for an enlarged right ovary seen on ultrasound with other possible masses on the uterus and in the peritoneum. Exploration reveals these masses to be endometriosis including a chocolate cyst (endometrioma) of the right ovary, right fallopian tube and peritoneum. The endometriomas are all small, less than 5 cm, and laser is used to ablate them, except the ovarian cyst, which is excised. During the procedure the patient also has a tubal ligation. What are the CPT® and ICD-10-CM codes reported for this service?

Answer 20

d.
49203, 58611, N80.1, N80.2, N80.3, Z30.2

Response Feedback:
Rationale: The exploratory laparotomy is not a separately billable service because it is no longer just examination of the intraabdominal organs; it became a surgical procedure in which the endometriomas were destroyed by laser. Remember a surgical laparotomy always includes a diagnostic (exploratory) laparotomy. Look in the CPT® Index for Endometrioma/Abdomen/Destruction/Excision referring you to 49203-49205. 49203 is correct for destruction for 1 or more tumors with the largest less than 5 cm in diameter.
The second procedure is a tubal ligation (female sterilization in which the fallopian tubes are sealed or severed). Look in the CPT® Index for Fallopian tube/Ligation referring you to 58600, 58611. Add-on code 58611 is correct to report because the tubal ligation was performed at the same time as another intra-abdominal surgery. Modifier 51 is not appended because 58611 is an add-on code.
The endometriosis included the ovary and the right fallopian tube. Look in the ICD-10-CM Alphabetic Index for Endometriosis/ovary guiding you to code N80.1. Next look in the Alphabetic Index for Endometriosis/fallopian tube referring you to code N80.2. Then look for Endometriosis/peritoneal directing you to code N80.3. Reporting a diagnosis for the tubal ligation is found by looking in the Alphabetic Index for Encounter (with health service) (for)/sterilization guiding you to code Z30.2. Verify all codes in the Tabular List.

Question 21

A 62 year-old woman with a history of urinary incontinence and incomplete bladder emptying presents for sling urethropexy and repair of a cystocele. The sling urethropexy is performed using a prosthetic mesh. The anterior repair is also performed without difficulty and both repairs are performed vaginally. What are the CPT® codes reported for this service?

Answer 21

d. 57288, 57240-51
Response Feedback:
Rationale: The patient has urinary incontinence and her bladder is bulging downward through the anterior vaginal wall (cystocele). First a sling is placed under the junction of the urethra and bladder for suspension to correct the urinary incontinence. Look in the CPT® Index for Sling Operation/Vagina referring you to 57287, 57288. 57288 is correct as 57287 is for removal or revision of the sling. Next is the repair of the cystocele by tightening the front (anterior) wall of the vagina (colporrhaphy or anterior repair). Look in the CPT® Index for Vagina/Repair/Cystocele referring you to 57240, 57260. The insertion of the mesh, code 57267, is not coded for this scenario because it was used for the sling operation not the colporrhaphy. It is included in 57288. Modifier 51 is appended to 57240 to indicate additional procedures performed during the same session.

Question 22

What is the code for ultrasound evaluation of a fetus and mother, usually performed early in pregnancy (first trimester), to confirm fetal age, set an anticipated delivery date, for qualitative assessment of amniotic fluid volume/gestational sac shape and examination of the maternal uterus and adnexa?

Answer 22

b. 76801
Response Feedback:
Rationale: The service performed in this question is an ultrasound to evaluate the fetus and mother in the first trimester. In the CPT® Index look for Ultrasound/Obstetrical/Pregnant Uterus referring you to 76801, 76802, 76805, 76810-76817. Code 76801 is correct to report the evaluation of both the fetus and the mother in her first trimester. This scenario does not qualify for a non-stress test; there is no monitoring of the fetal heart.

Question 23

A woman with a long history of rectocele and perineal scarring from multiple episiotomies develops a rectovaginal fistula with perineal body relaxation. She has transperineal repair with perineal body reconstruction and plication of the levator muscles. What are the CPT® and ICD-10-CM codes reported for this procedure?

Answer 23

c.
57308, N82.3, N81.89

Response Feedback:
Rationale: The physician is closing a rectovaginal fistula (abnormal passage between the rectum and vagina). The repair is performed by a transperineal approach by reconstructing the perineal body (pertaining to the vulva and anus area between the thighs) by using a levator muscle plication. In the CPT® Index look for Fistula/Closure/Rectovaginal referring you to 57300, 57305, 57307, 57308. Code 57308 includes closure of rectovaginal fistula via a transperineal approach, with perineal body reconstruction, with or without levator plication.

Two diagnoses are reported for this scenario. The first diagnosis is rectovaginal fistula. Look in the ICD-10-CM Alphabetic Index for Fistula/rectovaginal referring you to N82.3. Your second diagnosis is perineal scarring. Look for Laceration/perineum/female/old (postpartal) referring you to code N81.89. Verify codes in the Tabular List.

Question 24

A pregnant patient presents to labor and delivery with the baby in a breech presentation. During the delivery the doctor attempts to turn the baby (version of the breech presentation) while it is still in the uterus. The baby turns but then immediately resumes his previous breech position. Can this service (the version of the breech) be billed? If so, what is the code?

Answer 24

a.
Yes, because the doctor did the work, even though the outcome was unsuccessful. Report this procedure with code 59412

Response Feedback:
Rationale: The physician can bill for this service separately. Look in the CPT® Index Version, Cephalic — see Cephalic Version. Look in the CPT® Index for Cephalic Version/of Fetus/External and you are referred to 59412. Verify in the numeric section.

Question 25

An 88 year-old widow with uterine prolapse and multiple comorbid conditions has been unsuccessful in the use of a pessary for treatment elects to receive colpocleisis (LeFort type) to prevent further prolapse and avoid more significant surgery such as a hysterectomy. The treatment is successful. What are the CPT® and ICD-10-CM codes reported for this procedure?

Answer 25

b.
57120, N81.4

Response Feedback:
Rationale: This surgical procedure of a colpocleisis is performed to prevent uterine prolapse. In this procedure, the walls of the vagina are sewn together. This obliterates the vagina and prevents uterine prolapse. It is only performed in patients not sexually active. In the CPT® Index, look for Colpocleisis or LeFort Procedure/Vagina referring you to code 57120.
The reason for the operation is uterine prolapse. In the ICD-10-CM Alphabetic Index look for Prolapse, prolapsed/uterus (with prolapse of vagina) referring you to code N81.4. Verify in the Tabular List.