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Wiki How to code visit for test results.

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Lucheena

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A patient had a colposcopy, CPT 57454, with Dx code 795.04. Bx comes back showing severe dysplasia. Patient returns to office in two weeks to go over test results & talk about next step in treatment/follow up. How do you code this return visit? We have been coding it as 99213 with the biopsy Dx, but there is no exam done so I thought about 99401 but not sure what Dx to use. Help...
 
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