Did you know nearly 10-15 percent of OB/GYN billing codes get denied every year? These denials are often because of minor coding mistakes or documentation errors. Despite all efforts, these stats are continuously increasing. In 2026, the main financial goal for OBGYN providers is to reduce the denial rate and overcome OBGYN revenue cycle gaps. With 3,596,017 births recorded in the USA, the urgency and restlessness of providers because of denial rates is understandable.
Still, despite how important OBGYN care is to women’s health, its billing can be surprisingly complex. One missed modifier or miscoded global bundle can cost a practice thousands in lost revenue or lead to frustrating denials. But how to overcome this gap and increase annual revenue? This guide will answer all your concerns related to billing of global maternity packages, ultrasounds, E/M visits, and gynecologic procedures. You’ll learn what makes a “global OB” code different. When to bill prenatal, delivery, and postpartum care separately, and which modifiers or coding pitfalls to watch out for.
Let’s start with the billing of basic routine gynecological care.
Regular gynecologic visits involve preventative services. These include services such as annual well-woman exams, screenings (Pap smears, HPV tests), and contraceptive counseling.
Below are common CPT Codes for OB/GYN for routine visits and procedures. We have also included typical OB/GYN diagnosis codes used for these patient encounters.
| CPT Code | Description | Notes / Modifiers |
|---|---|---|
| 99395 | A preventive visit for an established patient, such as the annual well-woman exam, includes a full history, a breast and pelvic exam, counseling, and appropriate screenings. It is routine care. | Choose the code by age: use 99394 for ages 12–17, 99395 for 18–39, 99396 for 40–64, and 99397 for patients 65 and older. If a separate, significant problem is evaluated at the same visit, add modifier -25 to the problem-oriented E/M code to show it is a distinct service from the preventive exam. |
| 99396 | Preventive visit, established patient age 40–64 – Annual GYN exam with breast and pelvic exam. | As above, use -25 modifier if a concurrent problem-focused E/M service is provided. These preventive codes are not problem-based E/M visits. |
| Q0091 | Screening Pap smear specimen collection (Medicare). Covers obtaining the cervical cytology specimen for the Pap test. | Medicare only: Q0091 can be billed in addition to the preventive visit for Pap collection. (Most private payers consider Pap collection part of the exam.) No modifier is typically needed when billed with a preventive visit for Medicare. |
| G0101 | Pelvic and breast exam (Medicare preventive screening). | Medicare only: G0101 covers the pelvic and clinical breast exam portion of a well-woman exam. Often billed with Q0091. Not used for non-Medicare payers (who rely on 9939x codes). |
| 88175 | Cytopathology, cervical or vaginal, collected in preservative fluid, automated thin-layer preparation (Pap test). | Lab procedure code for an automated Pap smear interpretation (e.g., ThinPrep with computer screening). 88142 is a similar code for manual screening of Pap. These are usually billed by the laboratory. Providers should still know them for documentation. No modifier; not typically billed by the physician's office unless performing in-house lab. |
| — | Contraceptive counseling (no specific CPT). | Time spent counseling on birth control is generally included in the E/M visit (preventive or problem E/M). If extensive, use prolonged service codes as applicable. Document counseling time. |
Routine Gyn CPT Notes: Annual exam codes (99381–99397 for new/established patients by age) include age-appropriate history, exam, and counseling. If an abnormal finding is encountered during a routine exam, you still use the preventive code plus an appropriate diagnosis (with or without an abnormal finding ICD). Modifier –25 is important when billing a separate problem visit on the same day as a preventive exam. For Pap smears, the collection is included for most payers (except Medicare Q0091), and the lab processing is billed with 88141–88175 OB/GYN billing codes. Always link the appropriate ICD-10 screening code (e.g., routine exam or Pap screening diagnosis) to the preventive service to indicate preventive care.
| ICD-10 Code | Diagnosis Description | Notes |
|---|---|---|
| Z01.419 | Encounter for routine gynecological examination without abnormal findings. | Used for an annual well-woman exam when no abnormalities are found. If an abnormal finding arises (e.g., a breast lump found during exam), use Z01.411 (with abnormal findings) instead. |
| Z12.4 | Encounter for screening for malignant neoplasm of the cervix (Pap smear screening). | Use the cervical cancer screening code when you perform a routine Pap test on a patient who still has a cervix. If the patient has had a hysterectomy and no longer has a cervix, report Z12.72 (screening for vaginal neoplasm, vaginal cancer). These codes make clear that the visit is for cancer screening. |
| Z11.51 | Encounter for screening for human papillomavirus (HPV). | Use if doing an HPV test (e.g., high-risk HPV co-test) as part of screening. Often billed alongside Pap screening code if applicable. |
| Z30.09 | Encounter for general contraceptive counseling and advice. | Use for visits primarily for birth control counseling (discussion of options, no actual device insertion at that patient encounter). If a contraceptive method is initiated, there are more specific codes (see Family Planning below). |
| Z30.011 | Encounter for initial prescription of oral contraceptive pills. | Use when the purpose of the visit is to start birth control pills (initial script). For other methods: Z30.014 for IUD prescription, Z30.013 for injectable, etc., or Z30.018 for other methods. Once the method is ongoing, use follow-up codes (e.g., pill surveillance Z30.40). |
| N89.8 | Vaginal discharge, unspecified. | Example of a common minor problem found during a routine exam. If the annual exam uncovers a benign issue (like a yeast infection causing discharge), this diagnosis can be added (with a problem E/M service if significant). (Other common benign findings: N72 Cervicitis, R10.2 Pelvic pain, etc.) |
Routine Gyn ICD-10 Notes: Use Z-codes to indicate preventive encounters. Z01.41X codes specify routine GYN exams (with/without abnormal findings). Link screening codes like Z12.4 (Pap smear) or Z11.3 (STI screening) when those tests are done as preventive care. For contraceptive management, Z30.xx codes are used, there are specific OB/GYN billing codes for initial prescription of various contraceptives and for surveillance of ongoing use (e.g., IUD in place). If the visit addresses problems (e.g., heavy menstrual bleeding, vaginal symptoms) in addition to the routine exam, assign the appropriate N-code or R-code for the condition and remember to use modifier -25 on the E/M service as needed.
Obstetric care includes routine prenatal (antepartum) visits, care during labor and delivery, and postpartum care. Many payers bundle OB services into “global” packages covering the entire pregnancy, but there are OB/GYN billing codes for partial services as well. Fetal monitoring and other special obstetric procedures are coded separately from routine visits. Below are common CPT codes for obstetric care, followed by ICD-10 codes for typical obstetric diagnoses.
Global Obstetric Package (Prenatal + Delivery + Postpartum):
| CPT Code | Description | Notes / Modifiers |
|---|---|---|
| 59400 | Routine obstetric care, including antepartum care, vaginal delivery (with or without episiotomy and/or forceps), and postpartum care. | Global OB code for a typical vaginal delivery care package. Covers approximately 13 prenatal visits, the delivery, and routine postpartum follow-up. Do not bill separate E/M or delivery codes when using the global code (with a few exceptions). |
| 59510 | Routine obstetric care, including antepartum care, cesarean delivery, and postpartum care. | Global OB code for a cesarean delivery case (planned or unplanned C-section). Covers prenatal, the surgery, and postpartum. Ancillary services (e.g., ultrasounds) are billed separately. |
| 59610 | Routine OB care for a VBAC including antepartum, vaginal delivery after a previous C-section, and postpartum care. | Used when a patient with a prior cesarean has a successful vaginal delivery (VBAC). Global package similar to 59400 but indicates the prior history of cesarean. |
| 59618 | Routine OB care for attempted VBAC that ends in C-section includes antepartum, cesarean delivery, and postpartum. | Used when a patient with a prior C-section attempts labor vaginally but ultimately requires a C-section. This global code acknowledges both the trial of labor and C-section delivery. |
Partial OB Services (if not billing globally):
| CPT Code | Description | Notes |
|---|---|---|
| 59425 | Antepartum care only, 4–6 prenatal visits. | Used if a provider renders only part of the prenatal care (e.g., patient transfers care). For 1–3 visits, use normal E/M codes. |
| 59426 | Antepartum care only, 7 or more visits. | “Complete” antepartum care (not including delivery) when the provider saw the patient for most of the pregnancy but did not do the delivery. Reported once per pregnancy per provider. |
| 59430 | Postpartum care only (separate postpartum visit). | Used if the provider only performs the postpartum exam (e.g., the patient delivered elsewhere but comes to you for a 6-week check). This covers routine postpartum care. |
| 59409 | Delivery only, vaginal (no antepartum/postpartum). | Vaginal delivery services only (single baby), without prenatal or aftercare. Use when another provider did the prenatal/postpartum care (or in emergency delivery scenarios). |
| 59410 | Vaginal delivery, including postpartum care. | If you did the delivery and also provided the postpartum follow-up (but not the prenatal care). |
| 59514 | Cesarean delivery only (no ante/postpartum). | Use if you perform a C-section delivery only. For example, a specialist is called just to do the surgery. |
| 59515 | C-section, including postpartum care. | C-section plus postpartum care, without antepartum care by that provider. |
| 59612 | VBAC delivery only (vaginal birth after cesarean, delivery only). | Vaginal delivery for a patient with a prior C-section, when you didn’t do prenatal care. |
| 59614 | VBAC delivery, including postpartum care. | VBAC delivery + postpartum, without prenatal by you. |
| 59620 | Attempted VBAC, C-section delivery only. | C-section for a failed trial of labor after cesarean, no postpartum. |
| 59622 | Attempted VBAC, C-section, including postpartum. | C-section (failed VBAC) plus postpartum care, without prenatal care by you. |
Other OB Procedure Codes:
| CPT Code | Description | Notes / Modifiers |
|---|---|---|
| 59025 | Fetal non-stress test (NST) – external electronic fetal monitoring for fetal heart rate response (typically antepartum) | Commonly done in late pregnancy for surveillance (e.g., high-risk or post-dates). Can be billed each time an NST is performed. No separate modifier needed; not part of the global OB package (can bill in addition). |
| 76815 | Ultrasound, obstetrical, limited (e.g., quick check of fetal position or fluid). | Limited OB scan to answer a specific question (not a full anatomy survey). Bill separate from global OB (ultrasounds aren’t included in 59400). If multiple gestation, use appropriate add-on codes for additional fetuses. |
| 59000 | Amniocentesis, diagnostic. | Transabdominal needle aspiration of amniotic fluid for testing (genetic, lung maturity, etc.). Ultrasound guidance (76946) is billed separately if used. Amnio is billed in addition to global OB care (not included in 59400/59510). |
| 59412 | External cephalic version (ECV), with or without tocolysis. | Manual turning of a breech fetus to head-down. This can be billed in addition to the delivery code (if performed on a separate day or prior to labor). If an attempted version is unsuccessful, append Modifier –52 (reduced services) to 59412. |
| S9986 | Not a CPT code, but often used by Medicaid: Notations for global OB. | Some payers (e.g., Medicaid) may require code S9986 (or internal codes) to indicate global OB package billing. Check specific payer billing rules. |
Obstetric CPT notes: The global OB codes—59400, 59510, 59610, and 59618 cover all care by one practice for the entire pregnancy. Do not bill extra E/M visits for routine prenatal care. Those visits are already included in the global fee. However, services outside normal prenatal care can be billed separately: e.g., amniocentesis, ultrasound, NST, external cephalic version, these are unbundled from global OB. If care is transferred or split, report the antepartum-only and postpartum-only codes that fit the situation. For delivery-only services with multiple births, code each delivery separately. Then add the required modifiers, such as –59 on the second delivery code, following the payer’s rules. When OB/GYN medical billing antepartum-care-only codes, record the total number of visits. This supports choosing 59425 versus 59426.
| ICD-10 Code | Diagnosis Description | Notes |
|---|---|---|
| Z34.01 | Encounter for supervision of normal first pregnancy, first trimester. | Used for routine prenatal care in a first-time mother in the first trimester. Codes in the Z34.0x series indicate a normal, uncomplicated first pregnancy (Z34.01 for 1st tri, Z34.02 2nd tri, Z34.03 3rd tri). No high-risk factors present. |
| Z34.81 | Encounter for supervision of a normal pregnancy, first trimester. | Used for routine prenatal care in a woman with prior pregnancies (multigravida) with no complications. Z34.8x series (e.g., Z34.81 first tri, Z34.82 second, Z34.83 third) covers normal subsequent pregnancies. If it’s not specified whether the first or subsequent pregnancy, Z34.91–Z34.93 (unspecified vs first) can be used. |
| Z34.93 | Encounter for supervision of normal pregnancy, third trimester, unspecified whether first or other pregnancy. | Example of a code for a routine late-term visit when it’s not specified if it's the first pregnancy. Generally, try to use the specific Z34.0x or Z34.8x code if known. |
| O80 | Encounter for full-term uncomplicated delivery. | This code indicates a normal delivery with no complications, a healthy mother and baby, full-term vaginal birth. Commonly used as the principal diagnosis on the delivery admission for an uncomplicated vaginal delivery. No other O codes should be present if O80 is used (it implies no complications). |
| O82 | Encounter for cesarean delivery without indication. | Used for a C-section that is done without a medical indication. It may include elective repeat C-section or maternal request, etc. Like O80, this code implies an uncomplicated course (except that delivery is surgical). Do not use other complication codes with O82. |
| Z39.2 | Encounter for routine postpartum follow-up. | Used for the 4–6 week postpartum checkup when everything is routine. If the mother is seen immediately after delivery (in hospital) for postpartum care, Z39.0 (encounter for care immediately after delivery) may be used; Z39.1 is for lactation counseling visits. Z39.2 is the typical postpartum exam code. |
| Z37.0 | Outcome of delivery: single live birth. | (Optional) Used on hospital delivery records to indicate outcome (one healthy baby). Not usually needed on outpatient claims. Z37.0 is automatically included in hospital billing for deliveries. Multiple births have different Z37 codes (e.g., Z37.2 twins). |
Obstetric ICD-10 Notes: For routine pregnancies, use Z34.x codes for prenatal visits to indicate supervision of a normal pregnancy. These codes are stratified by trimester and whether the pregnancy is the first or not. Every routine prenatal visit should have a Z34 code (or an O code if a complication arises). On the hospital delivery claim, an O code like O80 (normal delivery) or other labor/delivery complication code is typically the principal diagnosis, with a Z37.x outcome code as a secondary. Z39.x codes cover postpartum patient encounters. If a patient has a complication during pregnancy, do not use Z34 for that visit, use the appropriate O code (see high-risk section). For a normal, healthy pregnancy that ends in a routine delivery, O80 can be used on the delivery claim (and implies no other O codes should be listed). Always document trimesters for any O-code, as many require it.
This section covers common gynecological procedures ranging from office procedures (biopsies, colposcopies) to surgeries (D&C, hysterectomies, laparoscopies). Proper medical coding in OB/GYN of these procedures and their related diagnoses is critical for accurate OB/GYN medical billing. Below are frequently used CPT Codes for OB/GYN procedures and corresponding common ICD-10 OB/GYN diagnosis codes indicating why these procedures are done.
| CPT Code | Description | Notes / Modifiers |
|---|---|---|
| 57454 | Colposcopy of cervix (and vagina), with biopsy of cervix and endocervical curettage (ECC). | Colposcopy is performed after an abnormal Pap. 57454 is a common code when biopsies are taken and the endocervical canal is sampled. If no ECC is done, and only biopsy, use 57455; if no biopsy, 57452. No modifier needed if billed alone. If done with a separate E/M on the same day (unusual), use -25 on E/M. |
| 57522 | Loop electrosurgical excision procedure (LEEP) of the cervix. | Excision of cervical transformation zone using electrocautery loop, typically for high-grade dysplasia. This code includes the cervical biopsy/excision; do not bill colposcopy separately if colpo was used to visualize, it’s inherent to the procedure. Ensure the pathology report supports medical necessity. |
| 58100 | Endometrial biopsy, without cervical dilation. | Office biopsy of the endometrium (sample of uterine lining). It is done for abnormal uterine bleeding or surveillance of the endometrium. No dilation or anesthesia. If performed with a hysteroscopy, use the hysteroscopy with biopsy code instead. Often billed with an E/M (use -25 on E/M if the visit had a significant separate evaluation). |
| 58120 | Dilation and curettage (D&C) of the uterus, diagnostic and/or therapeutic (non-obstetrical). | Scraping of the uterine lining, often for abnormal bleeding or incomplete miscarriage (if not coded as abortion management). Use for uterine polyps or heavy bleeding when done as a standalone (not postpartum, not abortion). If done with hysteroscopy, use hysteroscopic code (58558 for D&C with scope). |
| 59812 | Treatment of incomplete abortion (miscarriage), any trimester, completed surgically (D&C). | This code is used when a patient has had a spontaneous abortion (miscarriage) and not all tissue has passed, requiring a surgical D&C to evacuate remaining products of conception. It’s an OB/GYN procedure, but it falls under abortion management codes. Do not use 58120 for an incomplete miscarriage – 59812 is correct for that scenario. |
| 58563 | Hysteroscopy with endometrial ablation (e.g., for heavy bleeding). | Hysteroscopic surgery to destroy the uterine lining (for menorrhagia). Common for the treatment of abnormal uterine bleeding after childbearing. If done with hysteroscopic fibroid removal or polypectomy, use other codes (58561, 58558). Ensure appropriate diagnosis (e.g., fibroids, AUB) is linked. |
| 58558 | Hysteroscopy, surgical, with polypectomy (removal of uterine polyp) ± D&C. | Removal of endometrial polyps under direct hysteroscopic visualization. If polyps are the cause of bleeding, this restores the normal cavity. Includes a D&C if performed. |
| 58150 | Total abdominal hysterectomy (TAH), unilateral or bilateral salpingo-oophorectomy (removal of tubes/ovaries) if performed. | One of the common codes for an open hysterectomy (through an abdominal incision). 58150 is TAH without specifying removal of tubes/ovaries (but includes if done). For hysterectomy, code choice depends on route (open abdominal vs vaginal vs laparoscopic) and whether tubes/ovaries are removed. (58150 series for abdominal; 58260 series for vaginal; 58570–58573 for total laparoscopic). |
| 58571 | Laparoscopic hysterectomy, total, uterus ≤250g, with removal of tubes and ovaries. | Example of a laparoscopic surgical code used for minimally invasive hysterectomy, including bilateral salpingo-oophorectomy. Suppose ovaries are left in situ, 58570. Weight >250g, use 58572/58573 accordingly. These codes reflect advanced laparoscopic surgery. |
| 58661 | Laparoscopy, surgical, with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy). | Common for ovarian cystectomy, oophorectomy, or tubal removal. For example, laparoscopic removal of an ovarian cyst or ovary. If both ovaries/tubes are removed, it is still one unit. If done on both sides, it is usually inherently bilateral (check code descriptor). Use modifier -50 if the code isn’t inherently bilateral and both sides are done. |
| 49320 | Laparoscopy, abdomen, diagnostic (peritoneoscopy). | A diagnostic laparoscopy to examine pelvic organs (e.g., for chronic pelvic pain, endometriosis evaluation) when no definitive surgical procedure is performed other than minor biopsies. If a surgery is done, code the surgical laparoscopy instead. No modifier needed unless multiple procedures are done via scope (then apply -51 for multiple procedures). |
| 56605 | Vulvar biopsy, one lesion. | For biopsies of vulvar lesions (e.g., vulvar dystrophy or lesion). If multiple lesions are biopsied, 56606 for each additional. Ensure to differentiate from colposcopic-directed vaginal biopsy (57455 if via scope). |
| J1050 | (Not a CPT; HCPCS J-code for medroxyprogesterone injection for Depo-Provera, 1 mg) | Included here as a reference: When administering Depo-Provera for contraception, the drug is billed with J1050 (per 1 mg, typically 150 mg = J1050 × 150). The injection administration is a CPT code (96372), and the visit would be an E/M or 99211 nurse visit. |
Gyn Procedure CPT Notes: Many gynecologic procedures have multiple codes depending on the specifics (extent, approach, number of lesions, etc.). Colposcopy codes (57452–57461) vary based on whether biopsy or treatment is done, ensure the correct code for what was performed. For example, 57454 is most common for colposcopy with cervical biopsies and ECC (endocervical curettage). If a LEEP is done, use the LEEP code (57522) instead of a simple biopsy code. Endometrial biopsy (58100) is often done in-office for abnormal bleeding; if done on the same day as an office visit, append -25 to the E/M code. Major surgeries like hysterectomy have many codes, choose based on surgical approach and any additional components (removal of ovaries, lymph nodes, etc.). Example: A vaginal hysterectomy (non-laparoscopic) would use 58260 series codes, whereas a laparoscopic hysterectomy uses 58570 series. When multiple procedures are done in one session (e.g., hysteroscopy with D&C and polyp removal), some OB/GYN billing codes bundle certain services; if distinct procedures are done, use Modifier –51 (multiple procedures) or -59 (distinct procedure) as appropriate to indicate separate services. Always check CCI edits for bundled services (e.g., D&C might be included in a broader procedure code). Proper documentation of medical necessity (linked ICD-10 diagnosis) is key for reimbursement on these invasive procedures.
| ICD-10 Code | Diagnosis Description | Notes |
|---|---|---|
| N87.9 | Dysplasia of cervix, unspecified (cervical intraepithelial neoplasia NOS). | Common diagnosis for an abnormal Pap smear result indicating cervical dysplasia (if not specified mild/moderate/severe). CIN I (mild) is N87.0 or N87.1; CIN II moderate is N87.2; CIN III/CIS is D06. Use appropriate code. These diagnoses justify colposcopy and LEEP procedures. |
| R87.619 | Atypical squamous cells (ASC-US) on cervical cytology, unspecified. | A very common abnormal Pap result code (ASC-US). For higher abnormalities: R87.614 (LSIL), R87.615 (HSIL), etc. Use the cytology result code on the claim for colposcopy to indicate why it was done (if a Pap result prompted it). |
| N95.0 | Postmenopausal bleeding. | Abnormal bleeding in a postmenopausal patient, a common indication for endometrial biopsy or ultrasound. Ensure to differentiate from N92._ codes (menstrual disorders in premenopausal women). Postmenopausal bleeding often warrants ruling out endometrial carcinoma (hence biopsy or D&C). |
| N92.0 | Excessive and frequent menstruation with regular cycle (menorrhagia). | Heavy menstrual bleeding is a frequent GYN complaint leading to workup or surgery (e.g., endometrial ablation CPT 58563, hysterectomy if severe fibroids). Other related codes: N92.1 (irregular bleeding between periods), N93.9 (abnormal uterine bleeding, unspecified). |
| D25.9 | Leiomyoma of uterus, unspecified (uterine fibroid). | Uterine fibroids are a leading cause of heavy bleeding and pelvic pain. Use D25.0–D25.9 depending on fibroid location (submucous, intramural, subserosal, unspecified). Fibroids are common indications for hysterectomy (58150, etc.) or myomectomy. |
| N80.9 | Endometriosis, unspecified. | Endometriosis (the presence of endometrial tissue outside the uterus) often causes pelvic pain and infertility, and is a reason for laparoscopy and surgical treatment. If the site is known, use specific codes (e.g., N80.1 endometriosis of the ovary, N80.0 endometriosis of the uterus). Use unspecified if not clearly localized. |
| N94.6 | Dysmenorrhea, unspecified (menstrual cramps). | Painful menstruation is a common GYN symptom. Primary dysmenorrhea (N94.4) vs secondary (N94.5) can be coded if known. This might justify workups like an ultrasound or trial of therapy. By itself, it is not a procedure indication unless severe. |
| N72 | Inflammatory disease of the cervix (cervicitis). | Cervicitis can cause abnormal discharge or bleeding. It may be treated medically, but persistent cervicitis or abnormal cervicitis on Pap (like atypical glandular cells) might require biopsy. Common in Pap results and typically treated with antibiotics unless suspicious. |
| N76.0 | Acute vaginitis. | Example of a common minor diagnosis (e.g., yeast infection, trichomoniasis falls here or N76.0/N76.2). Usually managed medically (not surgically), but can be coded on E/M visits. |
| R10.2 | Pelvic and perineal pain. | A general code for pelvic pain. Chronic pelvic pain might lead to a diagnostic laparoscopy (49320) to check for endometriosis, adhesions, etc. Could also be coded as R10.2 or N94.89 (other specified pelvic pain). |
Gyn Diagnosis ICD-10 Notes: Gynecologic procedures must be justified by appropriate diagnoses. For cervical procedures (colposcopy, LEEP), use the Pap smear findings or dysplasia codes (R87., N87.) to support medical necessity. For uterine procedures (biopsy, D&C, hysteroscopy), common indications include abnormal uterine bleeding (N92., N93.) or postmenopausal bleeding (N95.0), and uterine fibroids (D25.*) or polyps (N84.0). Always code to the highest specificity: e.g., if the Pap showed HSIL, code R87.613 (HSIL) rather than a nonspecific abnormal finding. If a condition is confirmed (like pathology confirms cervical intraepithelial neoplasia), use that diagnosis for definitive treatment visits instead of just the screening result. Multiple OB/GYN diagnosis codes may be needed, for example, a fibroid (D25.1) causing menorrhagia (N92.0). List all contributory diagnoses. Additionally, complication codes (if any) should be included (e.g., anemia due to fibroids D50.0) to fully paint the picture. Proper linkage of diagnosis to procedure on the claim form is crucial for insurer approval.
OB/GYN providers frequently order or perform imaging studies (like ultrasounds) and lab tests (Pap smears, cultures, etc.) as part of patient care. Below are common CPT Codes for OB/GYN imaging and laboratory services, along with relevant ICD-10 codes for OB/GYN medical billing telling for why these tests are done. (Imaging and lab services may be billed by the physician’s office if done in-house, or by the facility/lab performing them. Medical coding in OB/GYN knowledge helps in ordering and documentation regardless.)
| CPT Code | Description | Notes |
|---|---|---|
| 76830 | Ultrasound, transvaginal (non-obstetric pelvic ultrasound). | A high-frequency ultrasound probe is inserted vaginally to visualize pelvic organs (uterus, ovaries). Used for gynecologic evaluations: ovarian cysts, early pregnancy confirmation, etc. For OB use, 76817 is the analogous code for transvaginal ultrasound of a pregnant uterus. |
| 76856 | Ultrasound, pelvic (non-OB), real-time with image documentation; complete. | Standard pelvic ultrasound performed transabdominally. “Complete” exam evaluates the uterus, endometrium, ovaries, adnexa, and pelvic floor. If a limited exam (focused, e.g., just to check IUD placement or one organ), use 76857 (limited pelvic ultrasound). |
| 76801 | Ultrasound, obstetrical, first trimester, <14 weeks gestation; single or first fetus, complete study. | Initial OB ultrasound to confirm pregnancy, dates, and viability in the first trimester. If multiple gestation, use add-on 76802 for each additional fetus. After 14 weeks, use codes 76805 (initial complete ultrasound ≥14 weeks) and add-on 76810 for additional fetus. |
| 76805 | Ultrasound, obstetrical, ≥14 weeks (usually second trimester anatomy scan), single fetus, complete. | The anatomy survey ultrasound around 18-22 weeks falls here. Includes detailed evaluation of fetal anatomy, placenta, amniotic fluid, etc. If a more detailed scan due to high-risk indications is done, 76811 (detailed fetal anatomic ultrasound) may be appropriate. Use the 76810 add-on for each additional fetus in multi-gestation pregnancies. |
| 76815 | Ultrasound, obstetrical, limited (e.g., quick check of fetal position, heartbeat, or fluid). | A brief scan is typically performed in the later pregnancy for a specific assessment (presentation, fluid check, etc.). 76816 is a follow-up OB ultrasound (re-evaluation of something noted before). 76815 vs 76816 depends on whether it’s a distinct limited check or a re-check of a known issue. |
| 76818 | Fetal biophysical profile (BPP) with NST. | An ultrasound assessment of fetal well-being (fetal breathing, movement, tone, amniotic fluid) with a non-stress test on the same day. If NST is not done, 76819 (BPP without NST). Often done weekly for high-risk pregnancies (e.g., post-term, diabetes). |
| 77067 | Screening mammography, bilateral, 2-view study of each breast, including CAD. | Screening mammogram for women (typically age ≥40 or earlier if high risk). Use 77066 for a diagnostic mammogram (e.g., if there’s a lump, or follow-up of an abnormal screen). Medicare and many payers require an appropriate screening diagnosis (Z12.31) for 77067 to be covered as preventive. |
| 77080 | DEXA bone density scan, axial skeleton (e.g., hip/spine), one or more sites. | Dual-energy X-ray absorptiometry to screen for osteoporosis is commonly ordered in postmenopausal women. Use 77081 for the peripheral (forearm) if done. A diagnosis like Z13.820 (screening for osteoporosis) or M81.0 (osteoporosis) would justify. |
| 81025 | Urine pregnancy test (HCG), qualitative. | Office pregnancy test kit (yes/no result). Often done as a CLIA-waived test in GYN offices. If billing, use 81025 for the test itself. (If sent out to the lab, the lab will bill their code instead.) A common diagnosis is Z32.02 (encounter for pregnancy test, result negative) or Z32.01 (result positive). |
| J7307 | Transcervical uterine Ultrasound Ablation (Sonata) – (Example HCPCS code for newer procedure). | Just as an example of advanced procedures: J7307 is used for billing the Sonata® transcervical fibroid ablation device. Not common; included for awareness of device coding. |
Imaging CPT Notes: Ultrasound codes are separated into obstetric vs non-obstetric. It’s important to choose the correct code based on the patient’s pregnancy status and the purpose of the exam. OB ultrasounds (76801, 76805, etc.) are gestational-age specific and count fetuses (with add-on codes for multiples). Document the indication for every ultrasound, as payers often require a supporting diagnosis (e.g., pain, bleeding, fundal height issue, high-risk condition, etc.). For screening OB ultrasounds (like the routine anatomy scan), a code like Z36 (encounter for antenatal screening) is appropriate. For medically indicated ones, use the problem (e.g., O26.844 for fundal height lagging, etc.). Mammograms (77067) for screening should be billed with Z12.31 (screening for malignant breast neoplasm). If a mammogram is diagnostic (patient has a symptom), use symptom or history codes (e.g., N63 breast lump). Bone density scans (77080) are often billed with Z13.820 or menopause codes. Remember that many imaging codes require modifiers if multiple procedures are done on the same day: e.g., if two ultrasounds are done (abdomen and pelvic), use modifier –59 to denote separate studies if appropriate. Also, for multiple gestations on OB ultrasound, use the specific add-on codes (e.g., 76810, 76812) per fetus rather than separate line items with modifiers.
| CPT Code | Description | Notes |
|---|---|---|
| 88175 | Pap test (cytopathology), cervical or vaginal, thin-layer (automated screening). | This is the lab processing of a Pap smear using automated techniques (e.g., ThinPrep with computer-assisted screening). 88142 is the manual screening version. Only one of these is billed per Pap. The OB/GYN office typically doesn’t bill these unless they have an in-house pathology lab; usually, the outside lab bills it. Ensure to include a screening dx (Z12.4) or diagnostic dx on the lab order. |
| 87624 | HPV DNA test, high-risk types (e.g., HPV 16,18, and others by PCR). | This code is for high-risk HPV screening (often done from the same Pap specimen for women ≥30 or for ASC-US triage). If co-testing, the lab will bill this in addition to the Pap. Use Z11.51 (HPV screening) as a diagnosis for routine co-testing, or an abnormal Pap code if reflex HPV after ASC-US. |
| 87491 | Chlamydia trachomatis, amplified probe technique (NAAT). | 87591 for Neisseria gonorrhoeae NAAT. These are common STD tests (often performed together from a single swab or urine sample). For a combo Chlamydia/Gonorrhea test, labs might bill both codes. Use Z11.3 (encounter for screening for infections with a predominantly sexual mode of transmission) when screening asymptomatic patients, or use specific symptom or exposure codes if indicated. |
| 87880 | Rapid Streptococcus B test (Strep group B, by optic immunoassay). | Group B Strep vaginal/rectal screening in pregnancy at 35–37 weeks is often done by culture (87081) or NAAT. 87880 is a rapid test code (though many labs use culture or PCR coded differently). Use Z36 or O99.821 (streptococcus carrier state in pregnancy) as applicable. If using culture, appropriate microbiology CPT (87081). |
| 80081 | Obstetric panel (includes blood count, ABO/Rh, antibody screen, rubella, syphilis, hepatitis B, HIV) – full prenatal lab panel. | This panel code is used for initial prenatal labs (note: 80081 is the prenatal panel including HIV; 80055 was the older code without HIV; some payers still recognize 80055). Ordering this single code ensures all components are done. Use Z36 (antenatal screening) or Z34.xx for normal pregnancy as the diagnosis. Each component could also be ordered and coded separately. |
| 83036 | Hemoglobin A1c (glycated hemoglobin) testing. | Commonly ordered in PCOS patients or during pregnancy to screen for diabetes. In OB, a first prenatal A1c might be done for baseline or to detect unrecognized diabetes (use O99.81- and E11 or O24 if known diabetic). In Gyn, for PCOS or obese patients, screening for metabolic syndrome is recommended. Use appropriate ICD (e.g., Z13.1 for diabetes screening). |
| 82105 | Alpha-fetoprotein (AFP), serum (e.g., maternal serum AFP). | Part of the second-trimester screening (quad screen). Typically bundled in 80055/80081 if panel, but can be ordered standalone. Use Z36 (antenatal screening) as routine screening for neural tube defects. |
| 84702 | Chorionic gonadotropin (hCG), quantitative. | Serum quantitative beta-hCG test. Used to evaluate early pregnancy viability or to trend pregnancy hormone levels (e.g., in suspected miscarriage or ectopic). Use a relevant diagnosis like O02 (suspected miscarriage), or Z32.02 if just pregnancy test confirmation needed (though qualitative fits that better). 84703 is the qualitative serum hCG. |
| 82150 | Amylase, serum. | (Example of a non-OBGYN lab a gynecologist might order if evaluating abdominal pain to rule out other causes like pancreatitis.) Typically not routine, but OB/GYNs should use appropriate codes if ordering labs outside the typical GYN scope. Use symptom-based ICD for justification. |
Lab CPT Notes: Many lab tests in OB/GYN relate to preventive screening (Pap, HPV, STD tests) or pregnancy care (prenatal panels, glucose testing, etc.). For Pap smears, the collection is usually not separately billed (except Medicare Q0091), the lab’s CPT code (88175 or 88142) is what generates the charge for interpretation. Always ensure the diagnosis code on the lab order matches the purpose: e.g., Z12.4 for routine Pap, or an N87 code for surveillance Pap after prior dysplasia treatment. STD screening for asymptomatic patients should use Z11.3; if the patient has symptoms or exposure, use the appropriate N or O code (e.g., N89.8 vaginal discharge, O98.3x STI in pregnancy). The obstetric panel (80081) simplifies ordering initial prenatal labs, one code covers multiple tests (CBC, blood type, etc.). Remember that some components of panels have their own codes if ordered à la carte. When performing in-office tests (like urine pregnancy, dip UA, fern test for amniotic fluid, etc.), use the proper CPT and document CLIA if applicable. Modifiers: Most lab codes don’t require modifiers except in specific cases (e.g., repeat test same day might use -91 to indicate a repeat lab test). For example, if doing two hCG quant tests in one day (rare), -91 modifier on the second. Otherwise, each distinct test is its own line.
| ICD-10 Code | Diagnosis Description | Typical Use |
|---|---|---|
| Z12.31 | Encounter for screening mammogram for malignant neoplasm of the breast. | Use with 77067 (screening mammogram) to indicate it’s routine screening. Ensures coverage as preventive. If a diagnostic mammogram is used, use symptom code (e.g., N63 for lump) instead of Z12.31. |
| Z11.3 | Encounter for screening for infections with a predominantly sexual mode of transmission. | Use for routine STD screenings (chlamydia, gonorrhea, HIV, syphilis, etc.) when the patient has no symptoms and it’s a preventive screen (e.g., annual screen for sexually active under 25, pregnancy panel). This covers multiple tests. For specific screenings, there are specific codes (e.g., Z11.51 for HPV, Z11.4 for HIV). |
| Z36 | Encounter for antenatal screening of the mother. | Broad code for screening in pregnancy – covers tests like ultrasound screening for anomalies, glucose screening, etc. Often used for ordering the 20-week anatomy ultrasound (CPT 76805) or other standard prenatal screens. If a specific screening has its own code (like diabetes screening Z13.1), it can be used, but Z36 is general for “routine fetal/maternal screening.” |
| Z13.1 | Encounter for screening for diabetes mellitus. | In pregnancy, instead of Z36, one might use this for the glucose challenge test (which is part of routine prenatal care at 24-28 weeks). Also used outside pregnancy if screening a PCOS patient for DM. Ensure clarity if the payer prefers Z36 for the pregnancy context. |
| Z13.89 | Encounter for screening for other disorders. | Use as a catch-all for any screening that doesn’t have a specific code. For example, screening for ovarian cancer (no specific code; could use Z12.89, perhaps for other neoplasm screening or Z13.89). Use with caution; specify if possible. |
| Z32.01 | Encounter for pregnancy test, result positive. | Use when a pregnancy test is done and is positive (especially if that’s the main reason for the encounter, e.g., patient comes in to confirm pregnancy). For a negative result, use Z32.02. If the test is done as part of a routine exam or prior to a procedure, use those contexts accordingly. |
| Z30.430 | Encounter for insertion of an intrauterine contraceptive device (IUD). | If you are performing an IUD insertion (CPT 58300), this is the diagnosis to use, it indicates the visit is for IUD placement. Similarly, Z30.431 for IUD check/surveillance, Z30.432 for IUD removal, and Z30.433 for removal and reinsertion on the same visit. These ensure payers know it’s contraceptive management. |
| Z30.018 | Encounter for initial prescription of other contraceptives. | Use for prescribing contraceptives that don’t have their own specific code. For instance, if initiating the contraceptive patch or implant. It’s a general code if no specific method code applies. |
| Z30.2 | Encounter for sterilization. | Use when the visit/procedure is permanent sterilization (e.g., bilateral tubal ligation, salpingectomy for sterilization). If doing an elective tubal ligation (CPT 58670), link this code. |
| Z31.41 | Encounter for fertility testing. | Use for visits where the purpose is infertility evaluation (workup of a couple having trouble conceiving). This might involve HSG, semen analysis orders, labs, etc. N97.9 (female infertility) is usually the patient’s condition code, while Z31.41 can be used for the service encounter. |
Screening & Lab ICD-10 Notes: Always match the ICD-10 code to the intent of the test. Screening Z-codes (Z11–Z13 range) should be used when the patient has no signs or symptoms and the test is preventative. For example, use Z11.3 for routine STD screening in an asymptomatic patient. If the patient has a symptom or known exposure, use a problem or exposure code instead (e.g., Z20.2 for contact with STD). For pregnancy-related tests, Z36 is a versatile code indicating routine prenatal screening (ultrasounds, lab panels). Payers often expect Z36 on claims for the standard anatomy ultrasound or prenatal labs. Contraceptive management codes (Z30.x) are important for visits revolving around birth control, they justify IUD insertions, implant placements, etc. (Also use them alongside the procedure CPTs for devices). For infertility services, code the underlying infertility diagnosis (N97. for female infertility)* as well as any encounter code like Z31.41 for testing. Remember that many Z-codes for pregnancy and contraception are “primary only,” meaning they should be listed first when applicable (they represent the reason for encounter). When ordering labs like Pap or cultures, include the appropriate screening or diagnostic code on the requisition so the lab can bill correctly (e.g., Pap with Z12.4 or N87* if diagnostic). This ensures insurance knows the test was indicated.
OB/GYN practices also provide services related to contraception (birth control initiation, devices, sterilization) and evaluation/treatment of infertility. Below are key CPT procedure codes for family planning services and infertility treatments, with ICD-10 codes commonly associated with these encounters. Proper use of modifiers is important when multiple procedures are done together (e.g., IUD removal and insertion on the same day).
| CPT Code | Description | Notes / Modifiers |
|---|---|---|
| 58300 | Insertion of an intrauterine device (IUD). | Covers placing an IUD into the uterus. If an old IUD is removed and a new one inserted in the same visit, bill 58301 (removal) and 58300 (insertion) – append Modifier –51 on the second procedure. Do not bill an E/M for routine insertion unless significant separate issues were addressed (use -25 on E/M). |
| 58301 | Removal of intrauterine device (IUD). | Removal of an IUD. If a new IUD is immediately placed, see above for coding both procedures. |
| 11981 | Insertion of an implantable contraceptive device, subdermal (e.g., Nexplanon). | Use 11982 for removal, 11983 for removal with reinsertion. Typically, no E/M in addition unless separate issues addressed. |
| 58670 | Laparoscopy, surgical; with fulguration or transection of oviducts (tubal ligation). | Female sterilization via laparoscopic approach. Use payer-specific sterilization modifiers if required (e.g., -FP). Document consent if required. |
| 58661 | Laparoscopy with removal of adnexal structures (e.g., tubes/ovaries). | Can be used for sterilization via bilateral salpingectomy. Indicate it’s for sterilization (Z30.2). |
| 58700 | Salpingectomy, complete or partial, unilateral or bilateral (open surgical). | Open approach removal of tubes. Use CPT matching the approach and timing, link sterilization dx. |
| 55250 | Vasectomy, unilateral or bilateral (male sterilization). | Includes postoperative semen analysis. Use Z30.2 for sterilization encounter. |
| 58322 | Artificial insemination; intrauterine (IUI). | Each attempt billed per session. Usually accompanied by ultrasound (76857) and E/M. Document sperm preparation if done (lab code 89260). |
| 58970 | Follicle puncture for oocyte retrieval, any method (IVF egg retrieval). | Used in IVF procedures under anesthesia. 58974/58976 for embryo transfer (fresh/frozen). Global period considerations apply. |
| 89258 | Cryopreservation of embryos (laboratory service). | Lab code for IVF embryo freezing. Typically billed by the lab, not the physician. |
| 96372 | Therapeutic injection administration, subcutaneous or intramuscular. | Used for depot injections for contraception (e.g., J1050 Depo-Provera). Link with contraceptive management diagnosis (Z30.013 or Z30.42). Often billed with nurse visit 99211 if appropriate. |
| 99394 | Adolescent preventive visit (age 12–17, established patient). | Often used for initial contraceptive counseling as part of a well visit. If counseling-only visit, use office E/M with time-based coding if counseling dominates >50% of visit. |
Family Planning CPT Notes: Device insertion and removal codes (IUD, implants) are straightforward, but watch for scenarios where multiple procedures occur in one encounter. For example, when an IUD is removed and a new one is inserted in the same visit, you need to code for both. The general rule (if the payer doesn’t accept the combined ICD-10 code approach) is to bill 58301 and 58300, and append modifier -51 to indicate multiple procedures. Some payers might prefer modifier -59 on the second code to show a distinct procedure – check guidelines. Ensure device HCPCS codes are also billed if the practice supplied the device (e.g., J7298 for Mirena IUD device). For sterilization procedures, Medicaid often requires a secondary modifier or a specific consent form. Vasectomy (55250) is usually a simpler billing, but note it includes post-procedure sperm check (do not bill separately for those lab tests, they’re included in the global surgical package of 55250). Infertility treatment codes often are not covered by insurance (many plans exclude IVF, etc., or have separate coverage limits), so thorough knowledge of codes is important for patient counseling. If an OB/GYN is doing basic infertility (like ovulation induction and IUI), use the appropriate E/M codes for monitoring visits, ultrasound codes for follicle checks, and 58322 for the insemination. More advanced procedures (58970, 58974) are typically in specialized settings. Remember to use Modifier –52 if you intended to perform a procedure but had to abort or not complete it fully (e.g., difficult IUD insertion aborted midway – bill 58300-52 for discontinued procedure if appropriate). Always pair these services with the correct diagnosis codes (e.g., Z30.430 for IUD insertion, N97.1 for female infertility due to tubal factor, etc.) to avoid denials.
| ICD-10 Code | Diagnosis Description | Notes |
|---|---|---|
| Z30.430 | Encounter for insertion of an intrauterine contraceptive device. | Use this as primary diagnosis for IUD insertion (58300). For IUD removal, use Z30.432; for removal & reinsertion same day, use Z30.433; for IUD check/strings, use Z30.431. Indicates contraceptive management to payers. |
| Z30.018 | Encounter for initial prescription of other contraceptives. | Used for initiating contraceptive methods without a specific code (patch, ring, condoms, spermicide). For pills use Z30.011; injection Z30.013; implant Z30.017. Follow-up codes: Z30.40 (OCP), Z30.42 (injection), Z30.46 (implant). |
| Z30.2 | Encounter for sterilization. | Use for permanent contraception (tubal ligation, vasectomy). May require primary coding and consent for Medicaid. Can be used for counseling encounters without procedure. |
| Z31.01 | Encounter for fertility testing of female partner (subsequent pregnancy failure). | Used for initial fertility evaluation. Z31.41 is for general fertility testing encounters. Secondary to infertility diagnosis but can be primary for testing visits. |
| N97.9 | Female infertility, unspecified. | For difficulty getting pregnant when cause is unknown. Use specific N97.x codes after evaluation (e.g., N97.0 anovulation, N97.1 tubal, N97.2 uterine, N97.8 other). Often combined with Z31 codes for treatment. |
| N97.1 | Female infertility of tubal origin. | Blocked fallopian tubes (PID, etc.). Supports IVF or other fertility procedures. Male factor infertility is N46.9 on male partner’s record. |
| Z31.82 | Encounter for fertility preservation procedure (e.g., oocyte freezing). | For egg freezing prior to chemo or elective surgery. IVF for immediate conception may use other Z31 codes (e.g., Z31.84). |
| Z31.0 | Encounter for reversal of sterilization. | Use when patient seeks tubal reversal. CPT code for procedure: 58750. Shows payer the surgery is for restoring fertility. |
| O09.891 | Supervision of high-risk pregnancy with history of infertility, first trimester. | Used when an infertility patient becomes pregnant. High-risk coding ensures services like earlier ultrasounds or progesterone are justified. Use O09.891 (1st tri), O09.892 (2nd tri), etc. |
Family Planning/Infertility ICD-10 Notes: Contraceptive management encounters should always use Z30.- codes to denote the reason. For any procedure involving contraception (IUD, implant, sterilization), a Z30 code is usually primary. For example, an IUD insertion claim should list Z30.430 as the diagnosis to clearly indicate it’s not for treating a disease but for prevention. If the patient also has a medical condition that led to choosing that method (e.g., heavy bleeding and wanting an IUD to help, or BRCA positive opting for BSO – separate scenario), you can list that secondary. Sterilization cases: Z30.2 is critical; many insurers require it to process claims for tubals/vasectomies. Infertility: Distinguish between the patient’s condition (N97.x for female infertility, or N46.x for male partner’s issues) and the encounter’s purpose (Z31.x for services related to reproduction). Generally, put the infertility diagnosis (N97.x) as primary for treatment visits, with Z31.** as additional to indicate the type of service. For instance, an IUI cycle might have N97.1 (tubal infertility) and Z31.89 (other fertility procedure). Many infertility diagnoses are chronic – ensure to carry them on each related service. If doing tests like HSG (hysterosalpingogram), use the infertility diagnosis or Z31.41 (fertility testing). Note: Some payers don’t cover Z31.0 (reversal of sterilization) or certain infertility services, but medical coding in OB/GYN should still accurately reflect it. Always use the most specific infertility code available once known (unspecified N97.9 is a placeholder until workup is done). For male partner factors, if you are coding on a female’s chart (since you treat the couple), you might use Z31.61 (procreative counseling, female for male factor) or simply document in notes; typically, billing for male issues is done by his provider.
When a pregnancy is high-risk or complicated by maternal/fetal conditions, different codes come into play. This section lists CPT codes for special procedures often related to high-risk pregnancy management (beyond routine OB care), and ICD-10 codes for OB/GYN common high-risk pregnancy conditions. These ensure proper billing for the extra services and higher level of care involved.
| CPT Code | Description | Notes / Modifiers |
|---|---|---|
| 76811 | Ultrasound, detailed fetal anatomic examination, single fetus (usually second trimester). | Level II ultrasound for high-risk cases (anomaly suspected, maternal diabetes, etc.). Includes more detailed survey than 76805. Use 76812 for each additional fetus. Document reason (advanced maternal age, abnormal quad screen, etc.). |
| 76820 | Doppler velocimetry, fetal; umbilical artery. | Ultrasound Doppler of fetal circulation (IUGR, placental blood flow). 76821 for MCA, billed per study. High-risk indication required (e.g., O36.593). Not routine OB. |
| 59050 | Fetal monitoring during labor by consulting physician (with written report). | Used if outside MD interprets fetal heart tracings in complex labor. Separate report required. 59051 if no report. Rarely billed separately; usually part of delivery. |
| 59200 | Amnioinfusion, intra-amniotic infusion during labor. | Fluid infused into amniotic cavity for repetitive decels, low fluid, or cord compression. Billed in addition to delivery code. No modifier unless multiple distinct procedures. |
| 59320 | Cerclage of cervix, during pregnancy; vaginal approach. | Placement for cervical insufficiency (usually 12–14 weeks). Abdominal approach: 59325. Removal near term usually included in global OB. |
| 59412 | External cephalic version (ECV) of the fetus, with or without tocolysis. | Manual turning of breech/transverse fetus (~37 weeks). Billable in addition to prenatal care. Modifier -52 if attempt unsuccessful. Anesthesia billed separately if used. |
| 59821 | Treatment of missed abortion, 1st trimester (D&C for missed miscarriage). | For in utero fetal demise without miscarriage. <14 weeks (59821). Diagnosis: O02.1. Not to confuse with elective abortion codes 59840–59841. |
| 59070 | Transabdominal amnioinfusion (e.g., for polyhydramnios reduction) – uncommon. | Fluid drained or infused via amniocentesis outside labor. Rarely done. Some use 59001 for each additional. Check CPT Assistant for guidance. |
| 99199 | Unlisted special service (e.g., MFM care management fee) – not a standard code. | Used occasionally for high-risk care coordination. May not be reimbursed by all payers. Complex chronic care or unlisted codes may apply in unique scenarios. |
High-Risk OB CPT Notes: High-risk pregnancies often entail additional procedures and more frequent monitoring. Ultrasounds: a patient with a high-risk condition may get multiple ultrasounds; use the appropriate code each time (and trimester-specific codes as needed). A detailed anatomy scan (76811) is only billable in the presence of risk factors or abnormal findings – document the indication (like O35.1XX suspected fetal malformation) to justify it. Doppler studies (76820/76821) are usually in IUGR or fetal anemia scenarios – use with O36.xx codes. Cerclage (59320) is a distinct surgical procedure and can be billed separately from OB global (append modifier -59 if the global OB code might otherwise bundle it, but typically OB global includes only routine services, not surgeries like cerclage). Check payer rules – some require a modifier to unbundle from the global OB. External version (59412) can be billed with the global OB code (it’s not included). If the patient then delivers via C-section, you still keep the ECV code separate. Use -52 if not completed fully (attempted). Amniocentesis for genetic or fetal lung maturity (59000), we covered in the OB section – those are also high-risk related. Abortive outcomes: missed abortion treatment (59820-59821) and other OB surgery for complications are separate from routine OB care and billable in addition to global (often global OB gets broken in such cases because pregnancy didn’t continue to delivery with that provider). Documentation is key to showing these were medically necessary interventions for complications. Modifiers: If a high-risk procedure is done on the same day as a routine OB visit or another procedure, use -25 on the E/M or -59 on the procedure to delineate. Example: patient comes in for a routine prenatal visit but has low fluid -> an external version is attempted the same day. Bill 59425 (if antepartum only scenario) or part of global (no E/M separate if global), and 59412 (ECV) with no modifier codes needed as it’s a procedure distinct from a visit. However, if you did do an E/M for another reason plus procedure, -25 on E/M, also, some high-risk services might be non-covered (like maternal transport coordination), but still document them.
| ICD-10 Code | Diagnosis Description | Notes |
|---|---|---|
| O09.891 | Supervision of high-risk pregnancy, first trimester. | Use for unspecified or combination high-risk issues in 1st tri. O09.892 for 2nd tri, O09.893 for 3rd tri. Often replaces Z34 for high-risk moms. Document risk factors. |
| O10.911 | Pre-existing hypertension complicating pregnancy, first trimester. | Chronic HTN before pregnancy or <20 weeks. Use O11.9X for superimposed pre-eclampsia. Gestational HTN >20 weeks without proteinuria: O13.9. |
| O14.03 | Mild to moderate pre-eclampsia, third trimester. | O14 split by trimester/severity. O14.03 = mild, third tri. O14.1x = severe, O14.2 = HELLP. Justifies increased monitoring, early delivery, magnesium therapy. |
| O24.410 | Gestational diabetes mellitus in pregnancy, diet-controlled. | O24.4xx = diet, insulin, oral meds by trimester. O24.410 = diet-controlled. Requires frequent visits, ultrasounds, NSTs. Postpartum follow-up: O24.43. |
| O36.5930 | Maternal care for suspected fetal growth restriction, third trimester. | O36.59x = IUGR suspicion. O36.5930 = third tri, unspecified fetus. Justifies Dopplers, BPPs, early induction. Suspected macrosomia: O36.6xx. |
| O36.8910 | Maternal care for other specified fetal problems, first trimester. | Used for fetal issues without specific code. If known fetal anomaly exists, use O35 series. Choose correct code depending on fetal condition. |
| O30.003 | Twin pregnancy, third trimester, unspecified placenta/amniotic sacs. | O30 = multiple gestation. O30.003 = twin, 3rd tri, unspecified chorionicity. Always code multiple gestations. Add complication codes if present (e.g., O43.03 twin-twin transfusion). |
| O42.01 | Premature rupture of membranes (PROM), onset of labor <24h, first trimester. | O42 codes for early water breaking. Use exact code for gestational age/labor status. High-risk, may require hospitalization or induction. |
| O44.13 | Placenta previa with hemorrhage, third trimester. | O44.x = placenta covering os, with/without bleeding. O44.13 = hemorrhage, third tri. Justifies urgent C-section. No hemorrhage: O44.03. |
| O72.1 | Postpartum hemorrhage, delayed/secondary. | PPH after 24h–6 weeks. O72.0 = immediate PPH. High-risk patients may have higher PPH risk. Use with procedures like D&C (59160) if applicable. |
| O75.82 | Maternal exhaustion (labor-related). | Other unspecified complications of labor/delivery. Rarely billed, may document extreme maternal fatigue affecting management. |
| O85 | Puerperal sepsis (postpartum infection). | Postpartum infection/endometritis after delivery. High-risk post-C-section/prolonged labor. Treatment captured with O85 + procedures if applicable. |
High-Risk Pregnancy ICD-10 Notes: Coding high-risk pregnancies often requires multiple codes: one for the underlying condition and one for the fact that it complicates pregnancy. The O09 series (supervision of high-risk pregnancy) is used in outpatient prenatal visits as a replacement for Z34 when risk factors are present. But it often should be accompanied by the specific reason why it’s high-risk (if one exists and has a code). For example, a 38-year-old pregnant woman: use O09.522 (elderly multigravida, second trimester) for advanced maternal age – this both flags high-risk and the reason (age). If no single factor, O09.89x is a generic high-risk supervision code. Always specify the trimester for these codes as required. During the pregnancy, if complications occur, use the appropriate O codes in the O10–O48 range. For instance, gestational hypertension (O13.x) or pre-eclampsia (O14.x) as above, or gestational diabetes (aO24.4x). These should be on every visit problem list once diagnosed, and as the principal diagnosis on any acute hospital visit due to that issue. Some O codes require additional codes: e.g., pre-existing diabetes in pregnancy (O24.0-) says also code the type of diabetes (E10–E11). Check the instructions in the ICD-10 book for each category. Fetal complications (O30–O36) codes are used when the mother’s care is affected by a fetal issue (IUGR, multiples, malposition, etc.). For example, O36.5930 for IUGR prompts more monitoring and possible early delivery. Always code multiple gestation (O30.xx) in a multiple pregnancy; it often modifies billing (like increased fee for twins in some cases, requiring the code). Many high-risk ICD-10 obstetric and gynecologic conditions also have outcome codes: e.g., if a mom has a complication during labor, you might use a code from O60–O77 on the delivery record. In outpatient antepartum management, stick to O09 and O10-O26 (maternal conditions) and O30-O36 (fetal conditions) mostly. After delivery, certain codes like O86–O92 cover postpartum complications (which might be managed by OB in the postpartum period). For instance, a postpartum infection (O86.04 endometritis) might be seen at a 2-week check – that’s a visit outside global (complication care is billable). Always ensure the linkage of diagnosis to procedure is clear: if performing an indicated early C-section due to severe pre-eclampsia, the claim for the C-section (59514 or 59510) should have O14.1x attached, not just a generic code. In summary, high-risk pregnancies generate more codes and require careful sequencing (the complication code often is primary for visits addressing it, with O09 secondary for supervision of high-risk). Use Z3A. Codes to indicate weeks of gestation on OB claims if required (some payers want Z3A.## to specify gestational age, especially with complications). This helps validate that trimester-specific codes match the actual gestational age.
Understanding and using the correct OB/GYN billing codes from CPT codes for OB/GYN to ICD-10 diagnosis codes is key to reducing claim denials and improving revenue cycle performance. By coding accurately for routine gynecologic care, obstetric services, procedures, and high-risk pregnancies, practices can ensure compliance, minimize errors, and secure timely reimbursement. Always link the right ICD-10 codes with procedures, apply modifiers correctly, and stay updated with the latest coding guidelines.
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