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Common Codes for Billing: Contraceptive Management For dates of service POST to October 1, 2015: Use Visits ICD-10 CM Codes

Procedure / Supply Method Codes ICD-10 Description

Oral Z30.011 Initiate OC E/M /S4993 Contraceptives Z30.41 Surveillance of OC (Includes refills) Z30.13 Initial prescription of injectable contraceptive E/M / Depo Provera / J1050 Z30.42 Surveillance of injectable contraceptive

Emergency E/M / check with payer Z30.012 Encounter for prescription of EC Contraception for code Z30.018 Initial prescription of other contraceptives Hormonal Patch E/M / J7304 Z30.49 Encounter for surveillance of other contraceptives Natural Family Counseling and instruction in natural to E/M Z30.02 Planning avoid Z30.018 Initial prescription of other contraceptives E/M / J7303 Z30.49 Encounter for surveillance of other contraceptives

No method Encounter for other general counseling and advice on con- E/M Z30.09 dispensed traception LARC’s (Long Acting Reversible Contraception) Encounter for initial prescription of IUD (not coded with IUD E/M Z30.014 insertion) 58300/J7300, J7301,J7297, Z30.430 Encounter for Insertion of IUD J7298 IUD 58300,58301/ J7300, J7301, Z30.433 Encounter for Removal and Re-insertion of IUD J7297, J7298 E/M Z30.431 Encounter for routine checking of IUD 58301 Z30.432 Encounter for Removal of IUD E/M Z97.5 Presence of IUD

11981 / J7307 Z30.018 I Initial prescription of other contraceptives

11982 Implant Encounter for surveillance of other contraceptives (includes E/M Z30.49 surveillance, removal and re-insertion of Implant) 11983 / J7307

E/M Z97.5 Presence of Implant

FREQUENTLY USED CODES Commonly Used ICD-10 Codes in Reproductive Healthcare

Female Reproductive Healthcare

Breast Conditions N60.(01/02) Solitary cyst of breast (R/L) N97.0 Infertility- C54.1 Cancer of N60.(11/12) Fibrocystic change (R/L) E23.0 Hypopituarism C54.2 Cancer of N61 Mastitis, NOS N97.1 Infertility-tubal origin C54.3 Cancer of fundus uteri N64.0 Fissure and of nipple N97.2 Infertility-uterine origin C54.9 Cancer of corpus uteri, unspec. N64.3 Galactorrhea N97.8 Infertility-cervical origin D25.9 Uterine myoma N64.4 Mastodynia N97.9 , NOS N84.0 Polyp of corpus uteri N63 Lump or mass in breast N84.8 Polyp of other parts of fem genital N64.51 Induration of breast N84.9 Polyptract of fem. genital tract, unspec. N64.53 Retraction of nipple N92.4 Perimenopausal menorrhagia N85.00 N64.59 Other signs/ symptoms in breast N95.0 Postmenopausal bleeding N85.4 Malposition of uterus N64.53 Retraction of nipple N95.1 Menopausal syndrome N85.6 Asherman’s syndrome O91.23 Mastitis, postpartum, unspec. N95.2 Atrophic N85.7 R92.8 Abnormal mammogram N95.8 Symptoms w artificial menopause N85.9 Disorder of uterus, NOS N95.9 Menopausal disorder NOS Urinary Tract C53.0 Endocervical cancer and Adnexa N30. 10 Interstitial cystitis w/o hematuria C53.1 Exocervical cancer C56.1 Malignant neoplasm of right ovary N30.11 Interstitial cystitis w/ hematuria C53.9 Cervical cancer, NOS C56.2 Malignant neoplasm of left ovary N34.3 Urethral syndrome D06.0 CIN 3 biopsy endocervix N83.0 N39.3 D06.1 CIN 3 exocervix N83.1 N39.41 Urge incontinence D06.7 CIN 3, other parts of cervix N83.20 Unspecified ovarian cysts N39.46 Mixed incontinence D06.8 CIN 3, cervix, unspecified N83.29 Other ovarian cysts R30.0 Dysuria N86 Erosion/ectropion cervix N83.51 Torsion of ovary and ovarian R32 , unspecified N87.9 Dysplasia, NOS N83.52 Torsionpedicle of R35.0 Urinary frequency N87.0 CIN 1 biopsy N83.53 Torsion of ovary, ovarian pedicle R35.8 Other polyuria N87.1 CIN 2 biopsy and fallopian tube R39.11 Urinary hesitancy N88,1 N83.9 Noninflammatory disorder of R39.14 Incomplete bladder emptying N88.2 Stricture/stenosis of cervix ovary, fallopian tube and broad R39.15 Urinary urgency N84.1 ligament, unspecified R39.16 Straining on urination R87.619 AGC cytology R87.610 ASC-US cytology Syndromes R87.611 ASC-H cytology G43.001 Migraine, without aura N89.0 Mild vaginal dysplasia R87.612 LSIL cytology G43.101 Migraine, with aura N89.1 Moderate vaginal dysplasia R87.613 HSIL cytology G43.829 Migraine menstrual,not intractable N89.3 Dysplasia of vagina, unspecified R87.810 High risk HPV-DNA positive G43.909 Migraine, unspecified N89.6 Tight hymenal ring R87.614 Cytologic evidence of malignancy G44.209 Headache, tension N89.8 Other specified noninflammatory R87.616 Lacking transformation zone G44.(221/229) Headache, chronic tension-type N89.9 Noninflammatorydisorders of vagina disorder, NOS R87.615 Unsatisfactory cytology (intractable/ not intractable) M60.8-851 Myofascial pain N94. (4/5/6) C51.9 Vulvar neoplasm, malignant N80.0 Endometriosis of uterus D07.1 VIN 3 N80.3 Endometriosis of pelvic N94.0 (primary/secondary/unspec.) N94.1 D28.0 Vulvar neoplasm, benign N80.6 peritoneumEndometriosis in cutaneous scar N94.2 L28.0 Lichen simplex chronicus N80.9 Endometriosis, unspecified L28.1 Prurigo nodularis N94.810 Vulvar vestibulitis N94.819 , NOS L90.0 Lichen sclerosus et atrophicus Gynecological Endocrine R10.10 Upper , unspecified L94.0 Localized scleroderma [morphea] L68.0 Hirsuitism L94.1 Linear scleroderma L68.1 Acquired hypertrichosis R10.2 Pelvic and perineal pain L94.3 Sclerodactyly L68.2 lanuginosaLocalized hypertrichosis R10.2 Pelvic and perineal pain N84.3 Polyp of vulva E28.310 Premature menopause R10.30 Lower abdominal pain, unspecified N90.0 VIN I E28.319 (symptoms)Premature menopause R10.32 Abdominal pain, LLQ N90.1 VIN 2 L68.3 (Polytrichia R10.33 Abdominal pain, RLQ N90.89 Other specified noninflammatory L68.8 Other hypertrichosis N90.9 Noninflamdisorders disof vulvavulva, and NOS perineum 256.4 PCOS R51 Headache, unspecified

E66.8 Other

E28.2 Obesity, morbid

E66.3 Overweight

F50.9 noEating sympt Disorder,oms) unspecified

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FREQUENTLY USED CODES Commonly Used ICD-10 Codes in Reproductive Healthcare (cont’d)

Male Reproductive Healthcare Male Reproductive Healthcare (cont’d)

A63.0 Penile lesion N52.03 Combined arterial insufficiency and E29.1 Testicular hypofunction corporo-venous occlusive ED F52.0 Hypoactive sexual desire disorder N52.1 ED due to diseases classified F52.21 Male erectile disorder elsewhere F52.4 Premature ejaculation N52.2 -induced ED F52.8 Other , not N52.31 ED following radical prostatectomy related to substance use N52.32 ED following radical cystectomy /psychological cond. N52.33 ED following urethral surgery I86.1 Scrotal varices N52.34 ED following simple prostatectomy K62.7 Radiation proctitis N52.39 Other post-surgical ED K62.89 Other specified diseases of anus N62 Gynecomastia and R10.2 Pelvic and perineal pain K62.9 Disease of anus and rectum, NOS R21 Rash, non-specific skin eruption R36.0 Urethral discharge w/o blood L23.9 Allergic contact dermatitis, R36.1 Hematospermia unspecified cause L24.9 Irritant contact dermatitis, R36.9 Urethral discharge unspecified

L25.9 unspecifiedUnspecified causecontact dermatitis, unspecified cause L30.0 Nummular dermatitis Counseling L30.2 Cutaneous autosensitization F17.(200-291) Tobacco Abuse L30.8 Other specified dermatitis F32.9 Depressive disorder, single episode L30.9 Dermatitis, unspecified F33.9 Depressive disorder, recurrent L66.3 Perifolliculitis capitis abscedens F41.1 Anxiety, generalized L73.1 Pseudofolliculitis barbae F50.9 Eating disorder, unspecified L73.8 Other specified follicular disorders R68.82 Decreased libido N34.1 Nonspecific urethritis (NGU) Z60.(0-9) Problems related to social N34.1 Non-specific urethritis environment N34.2 Other Urethritis Z71.(41-60) Counseling on substance N39.3 Stress incontinence use/abuse N39.43 Post-void dribbling Z71.3 Dietary surveillance and counseling N40.0 Enlarged prostate without lower Z71.7 Human Immunodeficiency virus urinary tract symptoms (HIV) counseling N40.1 Enlarged prostate with lower Z71.89 Other specified counseling urinary tract symptoms Z71.9 Counseling NOS N41.0 Prostatitis, acute N41.1 Prostatitis, chronic Complications N41.9 Prostatitis, NOS K68.11 Postprocedural retroperitoneal N43.(40/41/42) Spermatocele R55 abscessSyncope (vasovagal) unspec/single/multiple T50.99 Drug allergy or hypersensitivity N43.3 Hydrocele 5AT81.4x Infection following a procedure N44.00 Torsion of testis, unspecified xAT83.31 Mechanical breakdown of IUD N45.1 Epididymitis xAT83.32 Displacement of IUD N45.2 Orchitis xAT83.39 Other mechanical complication of N45.3 Epididymo-orchitis xAT83.49 IUDMechanical complication of implant N46.9 Infertility, male 8AT83.59 Infection due to IUD/implant in N47.0 Adherent prepuce, newborn xAT83.6x urinaryInfection tract due to IUD/implant in N47.1 Phimosis xA genital tract N47.2 Paraphimosis Other Signs and Symptoms N47.3 Deficient foreskin G93.3 Postviral fatigue syndrome N47.4 Benign cyst of prepuce R11.0 Nausea, alone N47.5 Adhesions of prepuce and glans R11.10 Vomiting, unspecified N47.6 Balanoposthitispenis R11.11 Vomiting without nausea N47.7 Other inflammatory diseases of R11.12 Projectile vomiting N47.8 prepuceOther disorders of prepuce R11.2 Nausea with vomiting N48.(30-39) Priapisms R50.2 Drug induced fever N48.1 Balanitis R50.2 Drug induced fever N48.9 Disorder of penis, unspecified R50.9 Fever, unspecified N50.9 Disorder of male genital organs R53.0 Neoplastic (malignant) related N52.01 EDNOS due to arterial insufficiency R53.1 fatigueWeakness N52.02 Corporo-venous occlusive ED R53.81 Other malaise

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FREQUENTLY USED CODES Commonly Used ICD-10 Codes in Reproductive Healthcare (cont’d) Infectious Conditions PID (Cont’d) Contraception (Cont’d) N72 Cervicitis N73.3 Female acute pelvic peritonitis Z30.431 IUD surveillance N73.6 Female pelvic peritoneal adhesions Chlamydia Z30.432 Removal of IUD (postinfecti ve) A56.19 Unspecified site Syphilis Z30.433 Removal + reinsertion of IUD A56.3 Proctitis (anus/rectum) Z30.49 Surveillance of other contraceptives A51.0 Primary genital syphilis Z30.8 Other contraceptive management A56.4 Pharynx A51.31 Condyloma latum Z30.9 A56.8 Chlamydial infection of other sites Contraceptive management, NOS A51.39 Other secondary syphilis of skin Z97.5 Presence of (intrauterine) device N34.1 Non-specific urethritis A51.5 Early syphilis, latent Z98.51 status N72 Cervicitis A52.11 Tabes dorsalis Z98.52 status A52.16 Charcôt's arthropathy (tabetic) Ectoparasites B85.3 Pediculosis (crab lice) Miscellaneous B86 Scabies Z23 (Prophylactic) vaccination N11.9 Chronic tubulo-interstitial nephritis, Z31.61 Natural FP to achieve pregnancy Genital Herpes N12 Tubulounspecified-interstitial nephritis, not A60.00 Herpesviral infection of urogenital specified as acute or chronic Z31.69 Procreative mgmt. - counseling: preconception care system, unspecified N13.6 Pyonephrosis A60.01 Herpetic ulceration of penis N30.00 Acute cystitis without hematuria F52.9 Sexual func. Problem-no psych cond. A60.02 Herpesviral infection of other male N30.01 Acute cystitis with hematuria Pregnancy Evaluation genital organs R30.0 Dysuria Z32.00 /exam - not confirmed A60.03 Herpesviral cervicitis R30.9 Painful micturition, unspecified A60.04 Herpetic vulvovaginitis Z32.01 Pregnancy test/exam, positive A60.09 Herpesviral infection of other R31.9 Hematuria, unspecified Z32.02 Pregnancy test/exam, negative urogenital tract R35.0 Frequency of micturition A60.1 Herpesviral infection of perianal skin Preventive Medicine Visits Vaginal Infection and rectum Z00.00 General adult medical exam w/o A60.9 Anogenital herpesviral infection, A59.01 Trichomonal vulvovaginitis abnormal findings unspecified B37.3 Candidiasis of vulva and vagina Z00.01 General adult medical exam w/ K62.6 Ulcer of anus, rectum N76.0 Acute vaginitis abnormal findings N76.1 Subacute and chronic vaginitis Genital Warts Z01.411 Gyn. Exam w/ abnormal findings N76.2 Acute Z01.419 Gyn. exam w/o abnormal findings A63.0 Anogenital (venereal) warts N76.3 Subacute and chronic vulvitis Z12.39 Screening breast exam B07.9 Viral warts, NOS

B08.1 Molluscum contagiosum Vulvar Infection & Inflammation Procreative Management Tinea cruris B97.7 HPV infection, unspecified site B35.6 Z31.41 testing (semen analysis) N75.0 Cyst of Bartholin's gland Z31.430 Testing of female genetic disease Gonorrhea (GC) N75.1 Abscess of Bartholin's gland Z31.438 Othercarrier geneticstatus testing of female A54.00 GC infection of lower genitourinary N75.8 Other diseases of Bartholin's gland Z31.440 Testing of male for genetic disease tract, unspecified N76.0 Acute vaginitis Z31.448 Othercarrier geneticstatus testing of male A54.01 Cystitis and urethritis, unspecified N76.1 Subacute and chronic vaginitis Z31.5 Genetic counseling A54.02 GC vulvovaginitis, NOS N76.2 Acute vulvitis Z31.61 Procreative counseling /advice using A54.03 GC cervicitis, unspecified N76.3 Subacute and chronic vulvitis A54.09 Other GC infection of lower N76.4 Abscess of vulva Z31.69 Preconception care (other genitourinary tract N76.6 Ulceration of vulva procreative management Z31.81 Encounter for male factor infertility A54.1 GC infection of lower genitourinary tract w/ periurethral & accessory Z31.82 inEncounter female patient for Rh incompatibility Former V codes Z31.89 Other procreative management gland abscess Cervical Cytology status Z31.9 Unspecified procreative mgmt. A54.21 Infection of kidney and ureter Pap to confirm recent normal Pap Z01.42 Z98.51 Tubal ligation status A54.22 Prostatitis after abnormal Pap A54.23 GC infection of other male genital Z98.52 Vasectomy status Z08 Vaginal Pap after hyst for cancer organs Z12.4 Screening Pap smear cervix A54.24 GC female PID Sexually Transmitted Infection Z85.41 History of cervical cancer A54.29 Other GC genitourinary infections Z11.3 Screening for bacterial STDs (GC) Z87.42 History of abnormal cytology/other A54.29 Other GC genitourinary infection abnormal diseases of genital tract Z11.4 Screening for HIV A54.5 Gonococcal pharyngitis Z11.51 HPV screening Contraception A54.6 Proctitis (anus/rectum) Z11.59 Screening for other viral diseases Z30.011 Prescribe oral contraceptives Z11.8 Chlamydia screening Pelvic Inflammatory Disease (PID) Z30.012 Encounter for emergency cont. Z20.2 Contact with or exposure to STI N70.11 Chronic Z30.013 Initial Rx of injectable contraceptive Z22.4 Carrier/suspected carrier of STI N70.12 Chronic Z30.014 Initial Rx of IUD Z71.1 Worried, well N70.13 Chronic salpingitis and oophoritis Z30.018 Initial Rx of other contraceptives Z71.7 HIV counseling N70.91 Salpingitis, unspecified Z30.019 Initial Rx of contraceptives, NOS Z71.89 Counseling on other STDs N70.92 Oophoritis, unspecified Z30.02 Natural FP to avoid pregnancy Z71.9 Counseling NOS N70.93 Salpingitis and oophoritis, unspec. Z30.09 Other contraception counseling Z72.51 High risk heterosexual behavior N71.0 Acute inflamm. disease of uterus Z30.2 procedure Z72.52 High risk homosexual behavior N71.1 Uterus: chronic inflamm. disease Z30.40 Z72.53 High risk bisexual behavior N73.0 Acute & pelvic cellulitis Contraceptive surveillance NOS Z30.41 Z86.19 Personal history of STI N73.1 Chronic parametritis & pelvic Surveillance of OC user Z30.42 Surveillance of injectable cont. N73.2 cellulitisUnspec. parametritis & pelvic Z30.430 Insertion of IUD cellulitis Page 3

Commonly Used Current Procedural Terminology (CPT) Codes in Reproductive Healthcare

Cervix Genital Wart Treatment Pregnancy 57452 Colpo, no biopsy 46900 Anal (<14), chemical 59200 Insert osmotic dilator 57454 Colpo, biopsy + ECC 46916 Anal (<14), cryosurgery 59812 Suction/incompl SAB 57455 Colpo, biopsy only 46922 Anal (<14), surgical excision 59820 Suction/ missed SAB 57456 Colpo, ECC only 46924 Anal (>15), any method 59830 Suction/ septic SAB 57460 Colpo + LEEP 54050 Penile (<14), chemical 57461 Colpo + LEEP cone 54056 Penile (<14), cryosurgery Ultrasound 57500 Cervical biopsy only 54056 Penile (<14), cryosurgery 76830 Transvaginal, non-OB 57505 ECC only 54060 Penile (<14), surgical excision 76857 Abd’l, limited, non-OB 57511 Cryotherapy 54065 Penile (>15), any method 76817 Transvaginal, preg 57513 Laser ablation 56501 Vulva (<14), any method 76801 Abdominal, preg <14 weeks 57520 Knife or laser cone biopsy 56515 Vulva (>15), any method 76805 Abdominal, preg, >14 weeks 57522 LEEP only 57061 Vaginal (<14), any method 57800 Dilation of canal 57065 Vaginal (>15), any method Uterus 58100 Contraception Office Lab 57170 Diaphragm, cap fitting 87205 Gram stain Vagina 58300 Insert IUD 87210 Saline/KOH microscopy 57100 Biopsy, simple 58301 Remove IUD 83986 Vaginal pH 57105 Biopsy, require suture 11976 Remove LNG implant 81000 Urinalysis, dip+ micro 57160 Pessary fitting 11981 Insert implant 81002 Urine dip only 57420 vagina 11982 Remove implant 81025 Pregnancy test, urine 57421 Colposcopy with biopsy(s) 11983 Remove+insert implant Other CPT Codes Vulva 96372 Office injection, therapeutic 56405 I&D abscess 90649 HPV-4 vaccine 90460 Vaccine administration through 56420 I&D Bartholin abscess 90650 HPV-2 vaccine age 18 56605 Biopsy, single J1055 Inject MPA for contraceptive use 9046 Each additional vaccine 56606 Biopsy, multiple J7300 Intrauterine copper contraceptive component 56820 Colposcopy vulva J7302 Levonogesterol releasing IUC 90471 Vaccine administration, 19 and 56821 Colposcopy with biopsy(s) J7303 Contraceptive supply, ring older J7304 Contraceptive supply, patch 90472 Each additional vaccine J7307 implant system, component including implant and supplies 99000 Conveyance of specimen from J0696 Injection, ceftriaxone office to lab J1050 Injection, DMPA, 1mg 36415 Collection of venous blood by Other dispensed rx: check with payer venipuncture

Commonly Used Evaluation and Management (E/M) Codes

Preventive Medicine Office Visits Other E/M Codes Modifiers New Estab Patient Age 99024 Post-op visit (surgical global) -21 Prolonged E/M services 99384 99394 12-17 yo 99401 Preventative counseling -24 Unrelated E/M service by same 99385 99395 18-39 yo 99441 Telephone E/M by clinician, clinician during surgical global 99386 99396 40–64 yo estab pt, 5 -10 mins period 99387 99397 > 65 yo 99442 Telephone E/M by clinician, -25 Significant, separately identifiable estab pt, 11-20 mins E/M service by same clinician on Problem-Oriented Office Visits 99443 Telephone E/M by clinician, same day of procedure/other See page 5. estab pt, 21-30 mins service -51 Multiple procedures (similar operation, same body area) -52 Reduced services -53 Discontinued procedure Key: See Page 5

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Commonly Used Evaluation and Management (E/M) Codes (cont.) Problem-Oriented Office Visits New Patient Established Patient 3 Key Components 3 Key Components Time Method Time Method Method Method FTF time HISTORY EXAM MDM FTF time HISTORY EXAM MDM Typical mins (range) Typical mins (range) 99201 PF PF Straight- 10 (≤ 15) 99211 Minimal Minimal Minimal 5 (≤ 7) forward 99202 EPF EPF Straight- 20 (16-25) 99212 PF PF Straight- 10 (8-12) forward forward 99203 Detailed Detailed Low 30 (26-37) 99213 EPF EPF Low 15 (13-20) 99204 Comp Comp Mod. 45 (38-53) 99214 Detailed Detailed Mod. 25 (21-33) 99205 Comp Comp High 60 (>53) 99215 Comp. Comp. High 40 (>33)

Level: All 3 must meet or exceed requirements Level: Two of three must meet or exceed requirements

Three Key Component Tables History Table for New Patient History Table for Established Patient History HPI ROS PFSH History HPI ROS PFSH Level # elements # systems # areas Level # elements # systems # areas

PF Brief N/A N/A Minimal N/A N/A N/A 1-3 elements

Brief Problem Brief Pertinent PF N/A N/A EPF 1-3 elements N/A 1-3 elements (1 sys) Problem Extended Extended Pertinent Detailed EPF Brief Pertinent N/A 4+ elements (2-9 sys) Any 1 of 3 1-3 elements (1 sys) Extended Complete Extended Extended Pertinent Comp. Complete Detailed 4+ elements (10-14 sys) -All 3 4+ elements (2-9 sys) Any 1 of 3 Choose level of lowest scoring subcomponent. Extended Complete Comp. Complete 4+ elements (10-14 sys) -Any 2 of 3 Choose level of lowest scoring subcomponent.

Physical Exam Table Medical Decision Making Table

Exam Level Single Organ Exam Elements Number of Data amt and Risk of MDM Level dx/mgmt PF 1-5 bullets complexity complications EPF ≥ 6 bullets options Detailed ≥ 12 bullets Straight- Minimal Minimal Minimal Comprehensive Female genitourinary exam + other organs forward 1 point 1 point Low Limited Limited Low Choose level based on number of bullets. 2 points 2 points Key Moderate Multiple Multiple Moderate Comp Comprehensive 3 points 3 points Estab Established High Extensive Extensive High EPF Expanded problem-focused 4+ points 4+ points

FTF Face-to-face Two of three elements must be met or exceeded. HPI History of present illness Mod Moderate NEC Not elsewhere classified NOS Not otherwise specified PF Problem-focused PFSH Patient, family, social history ROS Review of Systems This list is for informational purposes only. Always refer to the most recent version of the CPT 2015 Professional Edition and 2015 AMA ICD-10-CM for the most current codes. The National Training Center for Management and Systems Improvement is not responsible for any rejected claims. Note: Funding for this resource was made possible by the Office of Population Affairs (Grant FPTPA006023-01-00). The views expressed in written materials or publications do not necessarily reflect the official policies of the Department of Health and Human Services, nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government. Page 5