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complicated: HPV, 6 month f/u pap, wwe

  1. Question complicated: HPV, 6 month f/u pap, wwe
    Medical Coding Books
    I'm always confused when I code f/u paps w/ WWEs. Any advice/help is greatly appreciated! Thanks in advance

    cc: presents for 6 month f/u pap/WWE

    hpi hx: pt had pap in 12/07 coming back as ASCUS positive for high risk HPV. had colposcopy done 6/08. colpo bx confirmed high grade squamous intraepithelial lesions (focal CIN 2 in a background of CIN 1). the squamous dysplasia extends into endocervical glands. pt had leep 6/27/08. this is her f/u pap.

    exam: dr does full annual gyn exam including taking pap smear.

    dr dx: routine pelvic, screening pap, vd screen, HPV infection

    - what dx codes would you use?
    - does 795.05 include 079.4?

  2. #2
    This is what I would code:

    E/M--795.04, 079.4, plus a Dx code for whatever STD symptoms she was experiancing, if any.

    Pap: 795.04

    Reasoning being that HGSIL was the patient's most prominant diagnosis on the previous path report. HPV positive is a secondary diagnosis, and the 795.05 is trumped by the 795.04.

    Once the HGSIL is cleared after 3 "normal" paps if the practitioner wants to continue follow up paps on more than an annual basis then the diagnosis code on those future, hypothetical paps would be 795.05 unless the patient presents with a new, more serious diagnosis.

    Get it??
    Last edited by jonvieve; 07-21-2009 at 11:14 AM.

  3. #3
    p.s. I don't know what "WWE" stands for. And yes, 795.05 does include 079.4.
    Last edited by jonvieve; 07-21-2009 at 11:15 AM.

  4. Default
    WWE = Well Woman Exam

  5. #5
    the HGSIL is the definitive diagnosis after the bx was performed in 6/08.
    HPV and ASCUS is determined after a pap
    HGSIL is determined after a bx.

    HGSIL should be coded until a pap confirms the cells are gone.

    Melissa Freeman, RHIT, CCS-P, CPC

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