Female Genital System

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Female Genital System 1.Describe the structures associated with the female reproductive system 2.Use appropriate medical terminology to identify services and select codes 3.Apply the ICD-9-CM guidelines for assigning codes and the special guidelines for coding complications of pregnancy, childbirth and the puerperium 4.Select CPT® codes to describe the services and procedures related to the female reproductive system Objectives 3

Female Genital System External genitalia Mons pubis Labia (majora and minora) Hymen Bartholin’s glands Clitoris Urethra Anatomy 4

Female Genital System Internal Genitalia Vagina Uterus Cervix Fallopian tubes (“tubes” or oviducts) Ovaries Anatomy 5

Female Genital System 6

Diseases of the Genitourinary System – Complications of Pregnancy, Childbirth, and the Puerperium – Neoplasms V Codes –V01-V89 ICD-9-CM 7

Female Genital System Non-neoplastic Non-pregnant Related to… –Kidneys –Ureters –Bladder –Urethra –Breasts ( ) Benign conditions (eg, cysts) ICD-9-CM: Category

Female Genital System Have sequencing priority Report any condition that affects pregnancy (labor, delivery, post-partum) If pregnancy is incidental to condition treated, report V22.2 as secondary code –Must document that condition treated does not affect pregnancy Only for mother, not newborn ICD-9-CM: Category

Female Genital System Routine outpatient prenatal visits w/o complication First pregnancy –V22.0 Subsequent pregnancy –V22.1 First-listed Dx Not to be used with other Ch 11 Codes ICD-9-CM 10

Female Genital System High-risk Pregnancy Code from category V23 First-listed diagnosis May be reported with other Chapter 11 codes ICD-9-CM 11

Female Genital System Encounter w/ pregnant patient, no delivery Principal diagnosis is the complication(s) prompting the encounter –Complications are sequenced first Report all conditions treated during the encounter Cesarean delivery Principal diagnosis is the condition responsible for patient’s admission to labor and delivery ICD-9-CM 12

Female Genital System Categories Molar pregnancy Ectopic pregnancy –Pregnancy in other than uterine cavity 90% tubal pregnancy Categories Miscarriage Medically-induced abortion ICD-9-CM 13

Female Genital System Category Complications mainly related to pregnancy –Placenta previa, Hypertension, HIV, etc. Category Normal delivery Other indications in pregnancy, labor, and delivery Category Complications of labor, delivery and puerperium ICD-9-CM 14

Female Genital System Benign Malignant Code by location –Female breast (174) –Genitourinary organs ( ) Body of uterus Cervix Ovary Fallopian tubes ICD-9-CM: Neoplasms ( ) 15

Female Genital System Arranged by anatomy “outside to inside” –Terms used to describe external female genitalia Perineum Vulva Pudenda Introitus Consider terminology to determine procedure –-ectomy = removal –Hyster = uterus CPT®: Surgery ( ) 16

Female Genital System Vulva ( ) Vagina ( ) –Only CPT® code related to obstetrical complications NOT in labor/delivery section Cervix Uteri ( ) Os = opening of cervix CPT® 17

Female Genital System Corpus Uteri ( ) –Fundus = (body) of uterus –Endometrium = glandular lining tissue –Myometrium = muscular wall of uterus Excision –Biopsy < Myomectomy < Hysterectomy D&C –Scraping out endometrial tissue CPT® 18

Female Genital System Endoscopy Inspection of cavity/hollow organ using a scope –Laparoscopy = examination of abdominal cavity Surgical Endoscopy Always Includes Diagnostic Endoscopy CPT® 19

Female Genital System Hysteroscopy ( , 58579) Endoscopy of uterine cavity Oviduct/Ovary ( ) Tubal ligation Ovary ( ) CPT® 20

Female Genital System Spontaneous –Miscarriage Complete Incomplete –D&C (59812) may be required Induced ( ) –Therapeutic (medical termination of pregnancy) Failed induced abortion –Hysterotomy Abortion 21

Female Genital System Genetics Counseling –Time based (face-to-face) –Group counseling Non-physician Physician Vaccines –Administration ( ) –Drug supply –Modifier 25 for separate/significant E/M CPT®/Medicine Section 22

Female Genital System The End