Specialty Code Set Training Obstetrics and …

1 ICD-10-CMSpecialty Code Set TrainingObstetrics and Gynecology2014 Module 1ii ICD-10-CM Specialty Code Set Training Obstetrics and Gynecology 2013 AAPC. All rights course was current at the time it was published. This course was prepared as a tool to assist the participant in understanding how to prepare for ICD-10-CM. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility of the use of this information lies with the student. AAPC does not accept responsibility or liability with regard to errors, omissions, misuse, and misinterpretation.

2 AAPC employees, agents, and staff make no representation, warranty, or guarantee that this compilation of information is error-free and will bear no responsibility, or liability for the results or consequences of the use of this does not accept responsibility or liability for any adverse outcome from using this study program for any reason including undetected inaccuracy, opinion, and analysis that might prove erroneous or amended, or the coder s misunderstanding or misapplication of topics. Application of the information in this text does not imply or guarantee claims payment.

3 Inquiries of your local carrier(s) bulletins, policy announcements, etc., should be made to resolve local billing requirements. Payers interpretations may vary from those in this program. Finally, the law, applicable regulations, payers instructions, interpretations, enforcement, etc., may change at any time in any particular manual may not be copied, reproduced, dismantled, quoted, or presented without the expressed written approval of the AAPC and the sources contained within. No part of this publication covered by the copyright herein may be reproduced, stored in a retrieval system or transmitted in any form or by any means (graphically, electronically, or mechanically, including photocopying, recording, or taping) without the expressed written permission from AAPC and the sources contained Examples Used in this BookAAPC believes it is important in Training and testing to reflect as accurate a coding setting as possible to students and examinees.

4 All examples and case studies used in our study guides and exams are actual, redacted office visit and procedure notes donated by AAPC preserve the real world quality of these notes for educational purposes, we have not re-written or edited the notes to the stringent grammatical or stylistic standards found in the text of our products. Some minor changes have been made for clarity or to correct spelling errors originally in the notes, but essentially they are as one would find them in a coding setting. 2013 AAPC2480 South 3850 West, Suite B, Salt Lake City, Utah 84120800-626-CODE (2633), Fax 801-236-2258, 092313.

5 All rights , CPC-H , CPC-P , CPMA , CPCO , and CPPM are trademarks of AAPC. 2013 AAPC. All rights reserved. iii092313 ICD-10 ExpertsRhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, CPEDC, CENTC, COBGC VP, ICD-10 Training and EducationShelly Cronin, CPC, CPMA, CPC-I, CANPC, CGSC, CGIC, CPPM Director, ICD-10 TrainingBetty Hovey, CPC, CPMA, CPC-I, CPC-H, CPB, CPCD Director, ICD-10 Development and TrainingJackie Stack, CPC, CPB, CPC-I, CEMC, CFPC, CIMC, CPEDC Director, ICD-10 Development and TrainingPeggy Stilley, CPC, CPB, CPMA, CPC-I, COBGC Director, ICD-10 Development and TrainingRaemarie Jimenez, CPC, CPB, CPMA, CPPM, CPC-I, CANPC.

6 CRHC Director of Product Development/ICD-10 TrainerContentsGynecological Conditions..1 Routine GYN Exam ..1 Abnormal Pap Smear ..2 Fibroids ..3 Vaginitis ..4 Lichen .. 4 Menorrhagia ..5 Ovarian Cysts ..5 Menopausal Disorders ..6 Postmenopausal Bleeding ..6 Menopausal Climacteric States ..6 Postmenopausal Atrophic Vaginitis ..7 Pelvic Pain ..7 Prolapse ..8 Urinary Tract Infections ..9 Urinary Incontinence ..10 Cystitis ..11 2013 AAPC. All rights reserved. 1092313 Gynecological ConditionsObstetricians and Gynecologists treat female patients with a wide variety of conditions and diseases.

7 We will review the most commonly coded conditions, diseases and signs and symptoms for the female reproductive and urinary systems. Proper ICD-10-CM code selection for pregnancy and delivery will be addressed in a later section of this manual. Ligamentof ovaryMesosalpinxMesovariumFimbriaOvaryBr oad ligamentCervixUterosacralligamentBodyUte rine(fallopian tube)Fundus of uterusOvaryVaginaSuspensoryligaments Copyright OptumInsight. All rights reservedRoutine GYN ExamA large part of every OB/GYN practice is performing preventive medicine services. These services include yearly gynecological exams, screening pap smears and contraceptive maintenance.

8 When the patient presents for her yearly gynecological exam, there are two code options for the first listed diagnosis: Encounter for gynecological examination (general) (routine) with abnormal findingsThere is an instructional note following code to use additional code to identify the abnormal finding. Encounter for gynecological examination (general) (routine) without abnormal findingsThere are also instructional notes in this category to report screening vaginal pap smear, screening for HPV and to identify acquired absence of the uterus. When a screening pap smear is performed at the time of the routine gynecological exam, an additional code is not needed.

9 If a screening pap smear is performed independently (not part of the GYN exam), the correct code is 2 ICD-10-CM Specialty Code Set Training Obstetrics and Gynecology 2013 AAPC. All rights ConditionsEXAMPLE During the patient s annual gynecologic exam, the provider notices a breast lump. The provider performs a cervical pap smear and orders a diagnostic mammogram. Encounter for gynecological examination (general) (routine) with abnormal findings N63 Unspecified lump in breastAbnormal Pap SmearAbnormal Pap smear results can indicate various clinical conditions.

10 In ICD-10-CM, abnormal pap smears of the cervix and vagina are located in subcategory The documentation must include the location (cervix, vagina). The codes are further broken down by the cytology findings which include: Atypical squamous cells cannot exclude high grade squamous intraepithelial lesion on cytologic smear Atypical squamous cells of undetermined significance on cytologic smear Low grade squamous intraepithelial lesion (LGSIL) on cytologic smear High grade squamous intraepithelial lesion (HGSIL) on cytologic smear Cytologic evidence of malignancy on smear Inadequate smear Thin Preparation Unsatisfactory smear Satisfactory cervical smear but lacking transformation zone Other abnormal cytological findings on specimensCytology findings of an abnormal pap smear that are reported with other categories include: Human Papillomavirus (HPV) DNA Test results are reported with a code from category The HPV virus causes warts.