Report a Patient’s LEEP History Along With an O Care Code
Question: A pregnant patient came into our ob-gyn practice for an ultrasound at 16 weeks. The physician ordered the ultrasound to evaluate the patient’s cervix because the patient had a loop electrosurgical excision procedure (LEEP) in the past. What diagnosis codes should we report for the encounter? Ohio Subscriber Answer: Assign O34.42 (Maternal care for other abnormalities of cervix, second trimester) to indicate the patient presented for care related to the cervix during the second trimester. The second trimester typically consists of weeks 14 through 27 of the pregnancy. You mentioned that the patient previously underwent a LEEP. During a LEEP, the provider removes abnormal tissue from the surface of the patient’s cervix to test the tissue for precancerous cells. Use Z98.890 (Other specified postprocedural states) to report the patient’s personal history of LEEP. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
