Outpatient Procedural Coding for the Female Genital System

Codes Discussed: 56405-56821 (Female Genital System CPT code range), 57000-57426 (Vagina CPT code range), 57452-57800 (Cervix uteri CPT code range), 58100-58580 (Corpus uteri CPT code range), 58600-58770 (Oviduct/Ovary CPT code range), 58800-58960 (Ovary CPT code range), 58970-58999 (In vitro fertilization CPT code range), 59000-59076 (Antepartum and fetal invasive services CPT code range), 59100-59160 (Ectopic pregnancy treatment/excision CPT code range), 59300-59350 (Repair CPT code range), 59400-59430 (Vaginal delivery, antepartum, and postpartum care CPT code range), 59510-59525 (Cesarean delivery CPT code range), 59610-59622 (Delivery after previous C-section/VBAC CPT code range), 59812-59857 (Abortion CPT code range), 59866-59899 (Other maternity care and delivery procedures CPT code range), 49320 (Laparoscopy code referenced in laparoscopy code range), 58674-58554 (Laparoscopy code range as listed in the handout), 58555-58565 (Hysteroscopy code range), 58559 (Hysteroscopy with lysis of adhesions), 58660 (Laparoscopy with lysis of adhesions, separate procedure), 56405 (Incision and drainage of vulva or perineum), 56420 (Incision and drainage of Bartholin’s gland abscess), 53060 (Incision and drainage of Skene’s gland cyst or abscess), 56440 (Marsupialization of Bartholin’s gland cyst), 56501 (Destruction of vulvar lesion, simple), 56515 (Destruction of vulvar lesion, extensive), 53270 (Destruction of Skene’s gland cyst or abscess), 56605 (Biopsy of vulva or perineum, one lesion), +56606 (Each separate additional vulvar or perineal biopsy lesion), 56620 (Simple partial vulvectomy), 56625 (Simple complete vulvectomy), 56630 (Radical partial vulvectomy), 56633 (Radical complete vulvectomy), 56631 (Radical partial vulvectomy with unilateral inguinofemoral lymphadenectomy), 56634 (Radical complete vulvectomy with unilateral inguinofemoral lymphadenectomy), 56632 (Radical partial vulvectomy with bilateral inguinofemoral lymphadenectomy), 56637 (Radical complete vulvectomy with bilateral inguinofemoral lymphadenectomy), 56640 (Radical vulvectomy with inguinofemoral, iliac, and pelvic lymphadenectomy), 56820 (Colposcopy of vulva), 56821 (Colposcopy of vulva with biopsy), 57420 (Colposcopy of vagina with cervix, if present), 57421 (Colposcopy of vagina with cervix, if present, with biopsy), 57452-57461 (Colposcopy of cervix code range), 57200 (Colporrhaphy, suture of injury of vagina), 57210 (Colpoperineorrhaphy, suture of injury of vagina and/or perineum), 57240 (Anterior colporrhaphy, with or without repair of urethrocele), 57250 (Posterior colporrhaphy), 57260 (Combined anteroposterior colporrhaphy), 57265 (Combined anteroposterior colporrhaphy with enterocele repair), +57267 (Insertion of mesh or other prosthesis for pelvic floor repair, per compartment), 57268 (Repair of enterocele, vaginal approach), 52000 (Cystoscopy, included in cystocele repair codes), 45560 (Repair of rectocele code referenced with mesh add-on code), 57284 (Paravaginal defect repair, including repair of cystocele if performed, open abdominal approach), 57285 (Paravaginal defect repair, including repair of cystocele if performed, vaginal approach), 57423 (Paravaginal defect repair, including repair of cystocele if performed, laparoscopic approach), 57287 (Removal or revision of sling), 57288 (Sling operation for stress urinary incontinence), 51992 (Laparoscopic sling operation for stress urinary incontinence), 57452 (Colposcopy of cervix, including upper/adjacent vagina), 57454 (Colposcopy of cervix with cervical biopsy and endocervical curettage), 57455 (Colposcopy of cervix with biopsy of cervix), 57456 (Colposcopy of cervix with endocervical curettage), 57460 (Colposcopy with loop electrode biopsy of cervix/LEEP biopsy), 57461 (Colposcopy with loop electrode conization of cervix), 57505 (Endocervical curettage not done as part of dilation and curettage), 57520 (Cervical conization, cold knife or laser, without scope), 57522 (Cervical conization with loop electrode excision, without scope), 58100 (Endometrial sampling without dilation, with or without endocervical curettage), +58110 (Endometrial sampling/biopsy performed in conjunction with colposcopy), 58120 (Dilation and curettage, non-obstetrical), 58558 (Hysteroscopy with sampling, with or without dilation and curettage), 58260 (Vaginal hysterectomy, uterus 250g or less), 58290 (Vaginal hysterectomy, uterus over 250g), 58262 (Vaginal hysterectomy with removal of tube(s) and/or ovary(s), uterus 250g or less), 58291 (Vaginal hysterectomy with removal of tube(s) and/or ovary(s), uterus over 250g), 58263 (Vaginal hysterectomy with removal of tube(s) and/or ovary(s) and repair of enterocele, uterus 250g or less), 58292 (Vaginal hysterectomy with removal of tube(s) and/or ovary(s) and repair of enterocele, uterus over 250g), 58270 (Vaginal hysterectomy with repair of enterocele, uterus 250g or less), 58294 (Vaginal hysterectomy with repair of enterocele, uterus over 250g), 58541 (Laparoscopic supracervical hysterectomy, uterus 250g or less), 58543 (Laparoscopic supracervical hysterectomy, uterus over 250g), 58542 (Laparoscopic supracervical hysterectomy with removal of tube(s) and/or ovary(s), uterus 250g or less), 58544 (Laparoscopic supracervical hysterectomy with removal of tube(s) and/or ovary(s), uterus over 250g), 58570 (Laparoscopic total hysterectomy, uterus 250g or less), 58572 (Laparoscopic total hysterectomy, uterus over 250g), 58571 (Laparoscopic total hysterectomy with removal of tube(s) and/or ovary(s), uterus 250g or less), 58573 (Laparoscopic total hysterectomy with removal of tube(s) and/or ovary(s), uterus over 250g), 58550-58554 (Laparoscopic-assisted vaginal hysterectomy code range), 58550 (Laparoscopy with vaginal hysterectomy, uterus only, uterus 250g or less), 58553 (Laparoscopy with vaginal hysterectomy, uterus only, uterus over 250g), 58552 (Laparoscopy with vaginal hysterectomy with tube(s) and/or ovary(s), uterus 250g or less), 58554 (Laparoscopy with vaginal hysterectomy with tube(s) and/or ovary(s), uterus over 250g), S2900 (Robotic surgical system use, outpatient facility reporting), 58300 (Insertion of intrauterine device), 58301 (Removal of intrauterine device), 58350 (Chromotubation of oviduct, including materials), 58353 (Thermal endometrial ablation), 58356 (Endometrial cryoablation), 58563 (Hysteroscopic endometrial ablation), 58674 (Laparoscopic surgical ablation of uterine fibroids), 58545 (Laparoscopic myomectomy, 1-4 intramural myomas with total weight 250g or less and/or removal of surface myomas), 58546 (Laparoscopic myomectomy, 5 or more intramural myomas and/or intramural myomas with total weight greater than 250g), 58561 (Hysteroscopy with removal of leiomyomata), 58580 (Transcervical ablation of uterine fibroids), 58565 (Hysteroscopic intraluminal implant for tubal ligation), 58600 (Tubal ligation or transection, unilateral or bilateral), 58615 (Tubal occlusion by device using vaginal/suprapubic approach), 58671 (Laparoscopic tubal occlusion by device such as band, clip, or Falope ring), 58670 (Laparoscopic tubal fulguration with or without transection), 58661 (Laparoscopy with removal of adnexal structures, partial or total oophorectomy and/or salpingectomy), 58662 (Laparoscopy with fulguration or excision of lesions of ovary, pelvic viscera, or peritoneal surface by any method), 58672 (Laparoscopy with fimbrioplasty), 58673 (Laparoscopy with salpingostomy/salpingoneostomy), 58970 (Follicle puncture for oocyte retrieval, any method), 58974 (Embryo transfer, intrauterine), 58976 (Gamete, zygote, or embryo intrafallopian transfer, any method), 59000 (Diagnostic amniocentesis), 59001 (Therapeutic amniocentesis), 59012 (Cordocentesis), 59015 (Chorionic villus sampling, any method), 59150 (Laparoscopic treatment of ectopic pregnancy without salpingectomy and/or oophorectomy), 59151 (Laparoscopic treatment of ectopic pregnancy with salpingectomy and/or oophorectomy), 59160 (Curettage, postpartum), 59200 (Insertion of cervical dilator), 59812 (Treatment of incomplete abortion, any trimester, completed surgically), 59820 (Treatment of missed abortion, completed surgically, first trimester), 59821 (Treatment of missed abortion, completed surgically, second trimester), 59830 (Treatment of septic abortion, completed surgically), 59840 (Induced abortion by dilation and curettage), 59841 (Induced abortion by dilation and evacuation), 59870 (Uterine evacuation for hydatidiform mole)

Topics Covered: outpatient procedural coding for the female reproductive system, female genital system CPT coding, organization of CPT codes, procedural fundamentals, female reproductive anatomy, internal female reproductive anatomy, external female reproductive anatomy, vulva coding, perineum coding, introitus coding, vagina coding, cervix coding, cervix uteri coding, corpus uteri coding, uterus coding, ovary coding, oviduct coding, fallopian tube coding, in vitro fertilization coding, maternity care and delivery coding, antepartum procedures, fetal invasive services, ectopic pregnancy treatment, episiotomy repair, cervical cerclage, vaginal delivery services, global obstetric package, cesarean delivery services, VBAC delivery services, incomplete abortion treatment, missed abortion treatment, surgical abortion treatment, septic abortion treatment, hysteroscopy versus laparoscopy, hysteroscopic approach, laparoscopic approach, natural orifice procedure approach, percutaneous procedure approach, abdomen and abdominal wall approach, uterus visualization, lysis of adhesions coding, hysteroscopic lysis of adhesions, laparoscopic lysis of adhesions, LOA bundling, separate procedure designation, vulva anatomy, labia majora, labia minora, clitoris, vaginal opening, urethral meatus, perineum anatomy, introitus anatomy, incision and drainage coding, vulvar abscess drainage, perineal abscess drainage, Bartholin’s gland abscess drainage, Skene’s gland cyst drainage, Skene’s gland abscess drainage, Bartholin’s gland marsupialization, vulvar lesion destruction, Skene’s gland lesion destruction, laser surgery, electrosurgery, cryosurgery, chemosurgery, vulvar biopsy coding, perineal biopsy coding, multiple vulvar lesion biopsy coding, vulvectomy coding, simple vulvectomy, radical vulvectomy, partial vulvectomy, complete vulvectomy, inguinofemoral lymphadenectomy, iliac lymphadenectomy, pelvic lymphadenectomy, superficial subcutaneous tissue removal, deep subcutaneous tissue removal, vulvar area percentage documentation, colposcopy coding, vulvar colposcopy, vaginal colposcopy, cervical colposcopy, colposcopy with biopsy, vagina and cervix coding, suturing of vagina and perineum, non-obstetrical laceration repair, colporrhaphy coding, colpoperineorrhaphy coding, anterior colporrhaphy, posterior colporrhaphy, cystocele repair, rectocele repair, urethrocele repair, enterocele repair, mesh insertion for pelvic floor repair, pelvic floor repair by compartment, cystoscopy included in cystocele repair, paravaginal defect repair, lateral vaginal defect repair, stress urinary incontinence treatment, restoration of vaginal support fascia, open abdominal paravaginal repair, vaginal paravaginal repair, laparoscopic paravaginal repair, vaginal mesh insertion, sling operation coding, stress urinary incontinence coding, SUI, sling removal, sling revision, laparoscopic sling procedure, endocervical curettage coding, ECC coding, cervical biopsy coding, cervical conization coding, cone biopsy coding, LEEP coding, loop electrode excision procedure, colposcopy with LEEP biopsy, loop electrode conization with colposcopy, cold knife conization, laser conization, conization without scope, approach-based conization code selection, uterine tissue layers, endometrium, myometrium, perimetrium, endometrial sampling coding, endometrial biopsy coding, dilation and curettage coding, D&C non-obstetrical coding, hysteroscopy with sampling, hysteroscopy with D&C, hysterectomy coding, partial hysterectomy, subtotal hysterectomy, supracervical hysterectomy, total hysterectomy, complete hysterectomy, radical hysterectomy, vaginal hysterectomy, laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, LAVH coding, hysterectomy by uterine weight, uterus 250g or less, uterus over 250g, hysterectomy with removal of tubes and ovaries, hysterectomy with enterocele repair, hysterectomy surgical approaches, uterus delivered through vaginal canal, uterus removed through laparoscopic port, uterine structures cut laparoscopically, robotic surgical system reporting, outpatient robotic surgery coding, intrauterine device coding, IUD insertion, IUD removal, contraceptive device placement, hormonal IUD, copper IUD, Paragard, Mirena, Kyleena, Liletta, Skyla, chromotubation coding, oviduct chromotubation, methylene blue dye injection, fallopian tube patency testing, endometrial ablation coding, thermal endometrial ablation, cryoablation, hysteroscopic endometrial ablation, uterine fibroid treatment coding, laparoscopic uterine fibroid ablation, laparoscopic myomectomy, intramural myomas, surface myomas, uterine fibroid weight documentation, hysteroscopic leiomyomata removal, transcervical uterine fibroid ablation, ovaries and fallopian tubes coding, tubal ligation coding, female sterilization methods, hysteroscopic tubal implant, laparoscopic tubal occlusion, tubal band, tubal clip, Falope ring, tubal fulguration, tubal transection, adnexal structure removal, oophorectomy coding, salpingectomy coding, ovarian lesion fulguration, ovarian lesion excision, pelvic viscera lesion excision, peritoneal surface lesion excision, endometriosis coding, fimbrioplasty coding, fimbriae repair, salpingostomy coding, salpingoneostomy coding, ectopic pregnancy removal from fallopian tube, IVF outpatient procedures, follicle puncture, oocyte retrieval, embryo transfer, intrauterine embryo transfer, gamete intrafallopian transfer, zygote intrafallopian transfer, embryo intrafallopian transfer, obstetric outpatient procedures, diagnostic amniocentesis, therapeutic amniocentesis, cordocentesis, chorionic villus sampling, imaging guidance separately reportable with CVS, laparoscopic ectopic pregnancy treatment, ectopic pregnancy with salpingectomy, ectopic pregnancy with oophorectomy, postpartum curettage, cervical dilator insertion, laminaria insertion, prostaglandin insertion, nonviable pregnancy treatment, hydatidiform mole evacuation, CPT female genital system coding education, outpatient GYN coding, outpatient gynecologic procedure coding, medical coding webinar content