AAPC ch 13
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?
49203, 58611, N80.1, N80.2, N80.3, Z30.2
Physician performs an incision and drainage of an abscess located on the labia majora. What CPT® code is reported?
56405
The patient presents with a recurrent infection of the Bartholin's gland which has previously been treated with antibiotics and I&D. At this visit her gynecologist incises the cyst, draining the material from it and tacks the edges of the cyst open creating an open pouch to prevent recurrence. How is this procedure coded?
56440
A 56 year-old woman with biopsy-proven carcinoma of the vulva with metastasis to the lymph nodes has complete removal of the skin and deep subcutaneous tissues of the vulva in addition to removal of her inguinofemoral, iliac and pelvic lymph nodes bilaterally. The diagnosis of carcinoma of the vulva with 7 of the nodes also positive for carcinoma is confirmed on pathologic review. What are the CPT® and ICD-10-CM codes reported for this procedure?
56640-50, C51.9, C77.4, C77.5
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?
57120, N81.4
An ED physician treats a 30 year-old patient who was a victim of a rape. She has bruises and other trauma as well as a laceration of the vaginal wall, which is repaired with sutures (colporrhaphy) by the ED physician. What are the CPT® and ICD-10-CM codes reported for this procedure?
57200, S31.41XA, T74.21XA
Patient has a LEEP conization for CIN II. What are the CPT® and ICD-10-CM codes reported for this procedure?
57522, N87.1
Patient comes in with uterine bleeding. Physician performs a diagnostic dilation and curettage by scraping all sides of the uterus. What CPT® code is reported?
58120
A 63-year-old patient has severe intramural fibroids. The surgeon performs an open total abdominal hysterectomy with removal of the fallopian tubes and ovaries. What CPT® code is reported?
58150
A woman presents for hysterectomy after ECC (endocervical curettage) and EMB (endometrial biopsy) indicates endometrial cancer. Transabdominal approach (incision) is chosen for exposure of all structures possibly affected. The abdomen is thoroughly inspected with no gross disease outside the enlarged uterus but several lymph nodes are enlarged and the decision is made to perform a hysterectomy with bilateral removal of tubes and ovaries and bilateral pelvic lymphadenectomy with periaortic lymph node sampling. Specimens sent to pathology confirm endometrial cancer but find normal tissue in the lymph nodes. What are the CPT® and ICD-10-CM codes reported for this service?
58210, C54.1
A woman with abdominal pain and bleeding has a diagnosis of multiple fibroid tumors and undergoes laparoscopic resection without hysterectomy. After the abdomen is entered and inspected it is found she has 5 separate intramural fibroid tumors. The fibroid tumors are successfully removed, with a total weight of 300 grams. Pathology confirms leiomyoma (myomas or fibroids). What are the CPT® and ICD-10-CM codes reported for this service?
58546, D25.1
A 37 year-old woman presents with abdominal pain, bleeding unrelated to menses and an abnormal pap showing LGSIL (low grade squamous intraepithelial lesion). Treatment is hysteroscopy with thermoablation of the endometrium and cryocautery of the cervix. This is performed without difficulty. What are the CPT® and ICD-10-CM codes reported for this procedure?
58563, 57511-51, R87.612
A 52-year-old patient is scheduled for surgery for a right ovarian mass. Through an open incision, the surgeon finds a healthy left ovary. A right ovarian mass is visualized and the decision is made to remove the mass and the right ovary. What CPT® code is reported?
58940
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?
59074
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.
59151, O00.202
A 27 year-old woman's regular obstetrician delivers twins by cesarean delivery. Both are delivered without complications. Patient will have postpartum care in two weeks. What is/are the CPT® code(s) reported for this service?
59510
A patient delivers twins at 32 weeks' gestation for her first pregnancy. The first baby is delivered vaginally, but during the delivery, the second baby turns into a breech position. The physician decides to perform a cesarean delivery for the second baby. The physician also provided antepartum and postpartum care. How would the deliveries be reported?
59510, 59409-51
A patient with a previous low transverse incision cesarean delivery is attempting VBAC (vaginal birth after cesarean), also known as TOLAC (trial of labor after cesarean) with her second child. During labor her uterus ruptured. She had an emergency cesarean section followed immediately by hysterectomy to remove her ruptured uterus. Mother and baby survived. The same obstetrician provided her antepartum and postpartum care. What are the CPT® and ICD-10-CM codes reported for this service?
59618, 59525, O71.1, O34.211, Z3A.00, Z37.0
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?
76801
What is a bilateral structure of the female reproductive system?
All of the above
Which of the following are also know as the greater vestibular glands?
Bartholin's glands
What procedure is performed to treat vaginal prolapse?
Colpopexy
If you know that the suffix ~scopy means to use a scope to examine a body structure, what word means a scope procedure to examine the vagina?
Colposcopy
Choose the code for VIN III (CA in situ)
D07.1
The uterine adnexa refers to which 2 structures of the female reproductive system?
Fallopian Tubes
If a non-Medicare patient has an age and gender appropriate preventive medicine exam (i.e., a breast and pelvic exam) this is coded with the age appropriate Preventive Medicine codes from the E/M chapter of CPT®. If a Medicare patient has a breast and pelvic exam, how is this coded?
G0101
A 40 year-old presents with vaginal bleeding for several weeks unrelated to her menstrual cycle. The gynecologist orders an ultrasound to obtain more information for a diagnosis. What diagnosis code is appropriate for this encounter?
N93.9
A 68-year-old female presents with vaginal bleeding. It has been 5 years since her last period. Choose the code to describe her bleeding.
N95.0
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?
O09.893, Z3A.30
A woman with a long history of essential hypertension is managed throughout her pregnancy and delivers today. The hypertension has not resolved after the delivery. How is this coded?
O10.03
If a woman is hospitalized with severe pre-eclampsia in the 30th week of her pregnancy what is the diagnosis code for her daily visits?
O14.13, Z3A.30
A patient presents in her 15th 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?
O20.0, Z3A.15
A 32 year-old woman with a previous vertical incision for cesarean delivery presents in spontaneous labor with the baby in cephalic presentation. She has had an uneventful pregnancy and after laboring for 10 hours she delivers a single female child with brief use of a vacuum extractor over an episiotomy that is repaired by the delivering physician. There are no complications. What are the diagnosis codes for this delivery?
O66.5, O34.212, Z3A.00, Z37.0
A pregnant patient presents to the ED with bleeding, cramping, and concerns of loss of tissue and material per vagina. On examination, the physician discovers an open cervical os with no products of conception seen. He tells the patient she has had an abortion. What type of abortion has she had?
Spontaneous
The 2 structures that make up the uterus are:
Uterus and uterine tubes
Which one of the following is not part of the definition of code O80?
With forceps
What ICD-10-CM category is used to report the weeks of gestation of pregnancy?
Z3A
What does the abbreviation IVF mean?
invitro fertilization
