Wiki Colposcopy Coding Help

[Michael0630]

Hi all I am still new to OBGYN coding, however, I have a provider who did a Colposcopy on a patient but is using B97.7 as the primary dx. I know that DX is not able to be primary but this patient has had 2 PAPs the last 2 years and both came back normal except this is the SECOND year in a row that the patients pap was positive for HPV. I am attaching the note for help.

Any information is greatly appreciated! I thank you in advance!


Obstetric Comments
Menarche age 13

Have you received the HPV vaccine: No
Prior abnormal Pap: No
Prior colposcopy: No
Prior cervical treatment: no treatment
History of irregular bleeding: No

Socioeconomic History
• Marital status: Single
Tobacco Use
• Smoking status: Never
• Smokeless tobacco: Never
Substance and Sexual Activity
• Alcohol use: Yes
Comment: rare
• Drug use: Never

HCG test: negative

Review of Systems Review of Systems
Constitutional: Negative for activity change and appetite change. No weight gain and loss
HEENT: Negative for visual problems, eye pain, sinus congestion
Respiratory: Negative for apnea and chest tightness.
Cardiovascular: Negative for chest pain, palpitations and leg swelling.
Endocrine: Negative for cold intolerance, heat intolerance, polydipsia and polyphagia.
GI: Negative for diarrhea, BRBPR, melena, hematochezia, nausea, vomiting
Genitourinary: Negative for difficulty urinating, dysuria, flank pain, discharge
Musculoskeletal: Negative for back pain, knee pain, poor range of motion
Allergic/Immunologic: Negative for sinus pain, rash, swelling
Neurological: Negative for dizziness, seizures, light-headedness and numbness.
Hematological: Negative for bruising, Bleeding, swollen gland
Psychiatric/Behavioral: Negative for agitation, insomnia, loss of concentration

Physical Exam
Abdominal: Soft. Normal appearance. There is no tenderness.
Genitourinary: External genitalia shows normal pigmentation, no erythema; edema; masses; or lesions, labia symmetric; normal size. Urethra shows no discharge, no tenderness, no lesions. Rectum contains no hemorrhoids, masses, or tenderness; rectovaginal septum intact. Vagina/bladder shows no inflammation, lesions, nodularity, or masses; normal vaginal discharge. Adnexa displays no masses or tenderness, non-palpable. Cervix exhibits long, closed, firm; no lesions; no discharge or cervical motion tenderness. Uterus: normal size, mobile, non-tender, no masses.
Skin: Skin is warm and dry.

Indications:
Pap smear on 10/2023 showed normal, +HPV ( second year in a row).

Procedure Details
Was informed consent obtained? Yes
Was time out done? Yes

Findings:
Squamocolumnar Junction/Transformation Zone: fully visualized
Was the colposcopy satisfactory? Yes
Vaginal fornices: no abnormalities seen

Cervix: 11,4,7,1

ECC performed: Yes

Hemostasis obtained using: Monsel's solution

Patient tolerated the procedure well.

Post-op colposcopy instructions were given to patient: Yes

 

[csperoni]

Diagnosis code B97.7 is one of my many pet peeves. B97.7 is NOT the correct ICD10 for an HPV+ PAP test. Look at R87.8 __ __. There are several diagnosis codes for HPV+ PAP depending on high or low risk HPV and cervical vs vaginal specimen.
I realize many EMRs (the one my organization uses included), put B97.7 as the first choice when provider types "HPV". Just because it's at the top of their list does not make it the accurate diagnosis code.