SAMPLE - Society for Maternal-Fetal Medicine

DX
LK
2007 Outpatient Maternal-Fetal Services (Clinic Based)
CPT
CODE
MOD DESCRIPTION DX
LK
CPT
CODE
MOD
DESCRIPTION
MD VISITS
FETAL DIAGNOSTIC PROCEDURES
59425
Add 25 in MOD column if a procedure also performed on the same day
Prenatal Care ONLY (4-6 visits)
59000/
76946
26 Amniocentesis w/ US Guidance
59426 Prenatal Care ONLY (7 or more visits)
59015/
59430 Postpartum Care ONLY
76945
26 Chorion Villus Biopsy w/ US Guidance
99024 Routine Postpartum Visit
59012/
76941
26 Cordocentesis w/ US Guidance
NEW PATIENT VISITS
99201 Problem Focused (Straightforward) 10 minutes
59074 Fetal Fluid Drainage, including guidance
99202 Expanded Prob. Focused (Straightforward) 20 minutes
99203 Detailed (Low Complexity) 30 minutes
FETAL THERAPEUTIC PROCEDURES
99204 Comprehensive (Moderate Complexity) 45 minutes
59001 Amnio Fluid Reduction, including guidance
99205 Comprehensive (High Complexity) 60 minutes
59070 Transabdominal Amnioinfusion, including guidance
59076 Fetal Shunt Placement, including guidance
59072 Fetal Umbilical Cord Occlusion, including guidance
ESTABLISHED PATIENT VISITS
99212 Problem Focused (Straightforward) 10 minutes
99213 Expanded Prob. Focused (Low Complexity) 15 minutes
99214 Detailed (Moderate Complexity) 25 minutes
99215 Comprehensive (High Complexity) 40 minutes
OFFICE/OUTPATIENT CONSULTATIONS
99241 Problem Focused (Straightforward) 15 minutes
99242 Expanded Prob. Focused (Straightforward) 30 minutes
99243 Detailed (Low Complexity) 40 minutes
99244 Comprehensive (Moderate Complexity) 60 minutes
99245 Comprehensive (High Complexity) 80 minutes
FETAL ANTENATAL TESTING
76818 26 Biophysical Profile (w/ NST) #
76819 26 Biophysical Profile (w/o NST) #
59025 26 Non-Stress Test #
ULTRASOUND, ECHOCARDIOGRAPHY & DOPPLER PROCEDURES
76801 26 Complete Scan < 14.0 weeks
76802 26 Each additional fetus #
76805 26 Complete Scan > or = 14.0 weeks
76810 26 Each additional fetus #
76811 26 Complete Scan + Detailed Fetal Anatomy
76812 26 Each additional fetus #
76813 26 Nuchal Transluceny Screening
76814 26 Each additional fetus #
76815 26 Limited Ultrasound, (AFI, Viability, Fetal or Placenta Location)
76816 26 Follow-up/Repeat Ultrasound #
76817 26 Transvaginal OB (Cervical Length)
76856 26 Pelvic, GYN, Complete
76857 26 Pelvic, GYN, Limited or Follow-up (eg follicles)
76830 26 Transvaginal GYN
76700 26 Abdominal, Complete
76705 26 Abdominal, Limited (single organ, quadrant, follow-up)
76820 26 Doppler, Umbilical Cord, Initial or Repeat #
76821 26 Doppler, MCA, Initial or Repeat #
76825 26 Fetal Echocardiography, Initial #
76826 26 Fetal Echocardiography, Repeat #
76827 26 Fetal Cardiac Doppler, Complete #
76828 26 Fetal Cardiac Doppler, Repeat #
93325 26 Color Flow Mapping, when clinically indicated
76376 26 3 D Enhancement, when clinically indicated
93976 26 Uterine Artery Doppler
36460/
76941
26 Intrauterine Transfusion w/ US Guidance
59866/
76942 26 Multifetal Reduction w/ US Guidance
LABORATORY & MISCELLANEOUS PROCEDURES
57170 Diaphragm Fitting
59820 Dilation and Curettage (1st Trimester)
59821 Dilation and Curettage (2nd Trimester)
59412 External Cephalic Versions
82120/
83986
58300
Fem Exam (Amines, Vaginal Fluid, Qualitative and PH, Body Fluid)
Insertion of IUD
J7302
IUD Supply 5 Year
J7300
IUD Supply 10 Year
57160 Pessary Fitting
A4561
Pessary Supply (Rubber, any type)
A4562
Pessary Supply (Non-Rubber, any type)
59200 Placement of Cervical Dilators, Laminaria
99070 Laminaria Supplies #
59899 Removal of Cervical Cerclage (no anesthesia)
87210 Wet Mount Prep
10180 Wound I & D
S A M P L E
NURSING PROCEDURES
90772 Administration of Injection (Sub Q or IM)
J0704
Betamethasone, Number of Units______
90746 Injection of Hepatitis B Vaccine
90658 Injection of Influenza Vaccine (Whole Virus)
99211 Nursing Visit
90772/
J2790
Rhesus Immune Globulin Injection
99000 Specimen Collection/Handling (Office to Laboratory)
36415 Venipuncture (Routine)
MEDICAL NUTRITION THERAPY (Non-Physician)
97802 Initial Assessment, each 15 minutes #_________
97803 Re-assessment, each 15 minutes #_________
*Check with your payers to ensure reimbursement for these codes prior to usage.
TELEPHONE CALLS (Physician to patient or professionals)
99371 Simple or Brief Call
99372 Intermediate Call
99373 Complex or Lengthy Call
*Check with your payers to ensure reimbursement for these codes prior to usage.
Return visit:____________ weeks--____________ weeks or____________ days WITH____________ Same provider____________ Other provider:____________
Schedule other consultation:____________ IN____________ weeks or____________ days
Schedule ultrasound:____________ weeks or____________ days LMP:_____/_____/_____
FOR
_____________size < dates __________ size> dates __________ suspected IUGR __________ genetic ultrasound __________ dating _____________ follow-up for anomaly
_____________multiple gestation _________ cervical length _________ BPP _________ Other: ________________________________________
Provider Signature:_____________________________________________
SMFM Outpatient Encounter Form Copyright © 2006 Society for Maternal-Fetal Medicine 409 12th Street, SW, Washington, DC 20024-2188 ITEM 004

DX ICD-9 CODE DESCRIPTION DX ICD-9 CODE DESCRIPTION DX ICD-9 CODE DESCRIPTION
AMNIOTIC FLUID
658.03 Oligohydramnios
657.03 Polyhydramnios
658.13 PROM
658.23 PPROM
CARDIAC DISORDERS
648.53 Congenital Heart Disease
Specify:
648.63 Other Cardiac Disease
Specify:
CERVIAL/UTERINE PROBLEMS
654.63 Cervical Change
654.53 Cervical Incompetence
654.03 Congenital Uterine Anomaly
654.13 Uterine Leiomyomata
654.43/ 621.5 Uterine Synechiae
CNS ANOMALY
655.03 Agenesis of the Corpus Callosum
655.03 Anencephaly
655.03 Choroid Plexus Cysts
655.03 Encephalocele
655.03 Holoprosencephaly
655.03 Hydrocephaly
655.03 Microcephaly
655.03 Spina Bifida w/ Hydrocephalus
655.03 Spina Bifida w/o Hydrocephalus
CONGENITAL ANOMALIES
655.13 Fetal Chromosomal Abnormality
655.93 Known/Suspected, Unspecified
CONNECTIVE TISSUE
648.93/ 710.0 Lupus Erythematosus
648.73/ 714.0 Rheumatoid Arthritis
EARLY PREGNANCY
631 Blighted Ovum
634.92 Complete Abortion
633.XX
Ectopic Pregnancy
Specify:
646.33 Habitual Aborter (HX 3 SAB’s)
630 Hydatidform Mole
643.03 Hyperemesis, Mild
643.13 Hyperemesis, Severe
643.23 Hyperemesis>22 wks Gestation
634.91 Incomplete Abortion
632 Missed Abortion
640.03 Threatened Abortion
ENDOCRINE DISORDERS
648.03/ 250.XX Diabetes Mellitus (pre-pregnancy)
Specify:
648.83 Gestational Diabetes
648.13/ 242.9 Thyroid Disease (Hyperthyroidism)
648.13/ 244.9 Thyroid Disease (Hypothyroidism)
FETAL GROWTH PROBLEMS
656.53 Intrauterine Growth Restriction
656.63 Macrosomia
FETAL NON-CNS ANOMALIES
CARDIAC
655.83 Ebstein’s Anomaly
655.83 Echogenic Focus Heart (Non-specific)
655.83 Endocardial Cushion Defect (unspecified)
659.73 Fetal Arrhythmia
655.83 Hypoplastic Left Heart
655.83 Non-specific Congenital Heart
655.83 Tetralogy of Fallot
655.83 Ventricular Septal Defect
EXTREMITIES
655.83 Club foot
655.83 Polydactyly
655.83 Short Lower Extremities
655.83 Short Upper Extremities
FACE
655.83 Cleft Lip, Bilateral, Complete
655.83 Cleft Lip, Unilateral, Complete
655.83 Cleft Lip and Palate, Unspecified
GASTROINTESTINAL
655.83 Diaphragmatic Hernia
655.83 Duodenal Atresia
655.83 Echogenic Focus Bowel (Non-specific)
655.83 Esophageal Atresia
655.83 Gastroschisis
655.83 Omphalocele
655.83 Small Bowel Obstruction
FETAL NON-CNS ANOMALIES
CONTINUED
HYDROPS
653.73 Immune Hydrops Fetalis
653.73 Non-Immune Hydrops Fetalis
PULMONARY
655.83 CAM (Cystic Adenomatoid Malform)
655.83 Pulmonary Sequestration
RENAL
655.83 Bladder Outlet Obstruction
655.83 Hydronephrosis
655.83 Infantile Polycystic Kidney Disease
655.83 Multicystic Renal Disease
655.83 Renal Agenesis
655.83 UPV Obstruction
FETAL PRESENTATION
652.23 Breech Presentation
652.13 Breech = Vertex (Successful Version)
652.23 Breech (Unsuccessful Version)
652.33 Transverse or Oblique Lie
GASTROINTESTINAL DISORDERS
648.93/ 574.00 Cholelithiasis w/ Cholesystitis
648.93/ 574.20 Cholelithiasis w/o Cholesystitis
646.73 Cholestasis of pregnancy
646.73 Fatty liver of pregnancy
648.93/ 577.0 Pancreatitis
HEMATOLOGIC DISORDERS
648.93/ 287.4 Alloimmune Thrombocytopenia
648.23/ 280.9 Anemia (Fe Deficiency)
648.23/ 282.60 Anemia (Sickle Cell)
646.83/ 795.79 Antiphospholipid syndrome
648.93/ 287.3 Autoimmune Thrombocytopenia
649.33 Coagulation Defect
656.23 Other Red Cell Alloimmunization
648.93/289.81 Protein C Deficiency
648.93/ 289.81 Protein S Deficiency
656.13 Rh Alloimmunization
HYPERTENSIVE DISORDERS
642.03 Benign Essential Hypertension
642.73 Chronic Hypertension w/ Superimposed PIH
642.63 Eclampsia
642.33 Gestational Hypertension
642.13 Hypertension Due to Renal Disease
642.43 Mild Pre-eclampsia
642.53 Severe Pre-eclampsia
INFECTIOUS COMPLICATIONS
648.93/ 462 Acute Pharyngitis
647.23/ 099.53 Chlamydia
646.63/ 595.9 Cystitis (unspecified)
647.63/ 054.9 Genital Herpes
647.13 Gonorrhea
647.63/ V08 HIV Infection, Asymptomatic
647.63/ 042 HIV Infection, Symptomatic
647.03 Syphilis
Specify:
648.93/ 465.9 Upper Respiratory Infection (non-specific)
646.63/ 616.0 Vulvovaginitis (unspecified)
MULTIPLE GESTATIONS
651.03/655.83 Conjoined Twins
651.13 Triplets
651.43 Trips w/fetal loss & retention of =>1
651.03 Twins
651.03/663.83 Twin-Twin Transfusion Syndrome
651.33 Twins w/ 1 IUFD
651.23 Quadruplets
651.53 Quads w/fetal loss & retention of =>1
651.93 Quints or >
NEUROLOGIC DISORDERS
649.43/ 345.10 Epilepsy
649.43/ 358.1 Myasthenia Gravis
OBSTETRICAL PROBLEMS
654.23 Previous C-section
644.03 PTL (>22 wks)
OTHER FETAL PROBLEMS
655.73 Decreased Fetal Movement
656.43 IUFD (>22 wks)
PLACENTAL PROBLEMS
641.23 Placental Abruption
667.00 Placenta Accreta
641.13 Placenta Previa w/ Bleeding
641.03 Placenta Previa w/o Bleeding
663.53 Vasa Previa
PREGNANCY COMPLICATIONS
646.83/ 789.04 Abdominal Pain (LLQ)
646.83/ 789.02 Abdominal Pain (LUQ)
646.83/ 789.03 Abdominal Pain (RLQ)
646.83/ 789.01 Abdominal Pain (RUQ)
648.73 Back or Joint Pain
Specify:
649.23 Bariatric Surgery Status
649.13/278.00 Obesity
649.13/278.01 Obesity, Morbid
649.53 Spotting
649.03/305.1 Tobacco Use
671.13 Varicose Veins of Vulva
PREGNANCY DATING
V23.83 First Preg at < 16 yrs of age at EDD
V23.9 High Risk Preg (requires add. code)
V22.2 Incidental Pregnancy
V23.7 Insufficient Prenatal Care
645.13 Post-term Pregnancy (40-42 wks)
V72.41 Pregnancy exam/test, neg results
V72.40 Pregnancy exam/test, unconfirmed
645.23 Prolonged Pregnancy (> 42 wks)
656.13/V07.2 Rh Prophylaxis
V28.3 Screening malformations, via U/S
V23.84 Sub. Preg at < 16 yrs of age at EDD
V22.0 Supervision of Normal 1st Pregnancy
V28.8 Uncertain Gestational Age
649.63 Uterine size-date discrepancy
PRENATAL/FEMALE GENETICS
V26.31 Testing Genetic Disease Carrier
V26.32 Other Genetic Testing
V26.33 Genetic Counseling
PRENATAL / HX DIAGNOSIS
646.83/ 796.5 Abnormal Maternal Serum Screen
659.63 AMA (multigravida 35 or >)
659.53 AMA (primigravida 35 or >)
655.23 Hereditary disease Affecting Fetus
Specify:
V13.21 Personal HX of Preterm Labor
V26.4 General Counseling and Advice
V26.4 Preconception Counsel w/o Testing
Specify:
V26.3 Preconception Counsel and Testing
Specify:
V23.41 Pregnancy with HX Preterm Labor
V23.49 Pregnancy with other Poor OB HX
655.83/ 793.X Previous Abnormal Ultrasound
Specify:
655.53 Suspected Fetal Damage Drugs
Specify:
655.63 Suspected Fetal Damage Radiation
Specify:
655.63 Suspected Fetal Damage Viruses
POSTPARTUM PROBLEMS
675.12 or 4 Breast Abscess
674.24 Disruption of Episiotomy
670.02 or 4 Endometritis
V25.02 Fit Diaphragm/Cervical Cap
V25.09 General Contraceptive Counseling
674.32 or 4 Infection/ Hematoma of Abdominal Wound
V25.1 Insert IUD
V25.43 Insert Norplant
675.22 or 4 Non-purulent Mastitis
V25.01 Oral Contraceptive Prescription
648.44 Postpartum Depression
V24.2 Routine Postpartum visit
PSYCHIATRIC DISORDERS
648.33 Drug Dependence
Specify:
648.43 Psychiatric Disorders
Specify:
PULMONARY DISORDERS
648.93/ 493.90 Asthma w/o Status Asthmaticus
648.93/ 277.0 Cystic Fibrosis
RENAL DISORDERS
646.23 Gestational Proteinuria
646.23 Unspecified Renal disease w/o Hypertension
UMBILICAL CORD
663.83 Single Umbilical Artery
OTHER
*The above ICD-9 codes end with a fifth digit of 3 which denotes antepartum care. Plese remember to change the fifth digit to 0, 1, 2, or 4 when applicable.

DX
LK
2007 Outpatient Maternal-Fetal Services (Hospital Based)
CPT
CODE
MOD DESCRIPTION DX
LK
CPT
CODE
MOD
DESCRIPTION
MD VISITS
FETAL DIAGNOSTIC PROCEDURES
59425
Add 25 in MOD column if a procedure also performed on the same day
Prenatal Care ONLY (4-6 visits)
59000/
76946
26 Amniocentesis w/ US Guidance
59430 Postpartum Care ONLY
76945
59426 Prenatal Care ONLY (7 or more visits)
59015/
26 Chorion Villus Biopsy w/ US Guidance
99024 Routine Postpartum Visit
59012/
76941
26 Cordocentesis w/ US Guidance
99201 Problem Focused (Straightforward) 10 minutes
NEW PATIENT VISITS
59074 Fetal Fluid Drainage, including guidance
99202 Expanded Prob. Focused (Straightforward) 20 minutes
99203 Detailed (Low Complexity) 30 minutes
FETAL THERAPEUTIC PROCEDURES
99204 Comprehensive (Moderate Complexity) 45 minutes
59001 Amnio Fluid Reduction, including guidance
99205 Comprehensive (High Complexity) 60 minutes
59070 Transabdominal Amnioinfusion, including guidance
59076 Fetal Shunt Placement, including guidance
59072 Fetal Umbilical Cord Occlusion, including guidance
ESTABLISHED PATIENT VISITS
99212 Problem Focused (Straightforward) 10 minutes
99213 Expanded Prob. Focused (Low Complexity) 15 minutes
99214 Detailed (Moderate Complexity) 25 minutes
99215 Comprehensive (High Complexity) 40 minutes
OFFICE/OUTPATIENT CONSULTATIONS
99241 Problem Focused (Straightforward) 15 minutes
99242 Expanded Prob. Focused (Straightforward) 30 minutes
99243 Detailed (Low Complexity) 40 minutes
99244 Comprehensive (Moderate Complexity) 60 minutes
99245 Comprehensive (High Complexity) 80 minutes
FETAL ANTENATAL TESTING
76818 26 Biophysical Profile (w/ NST) #
76819 26 Biophysical Profile (w/o NST) #
59025 26 Non-Stress Test #
ULTRASOUND, ECHOCARDIOGRAPHY & DOPPLER PROCEDURES
76801 26 Complete Scan < 14.0 weeks
76802 26 Each additional fetus #
76805 26 Complete Scan > or = 14.0 weeks
76810 26 Each additional fetus #
76811 26 Complete Scan + Detailed Fetal Anatomy
76812 26 Each additional fetus #
76813 26 Nuchal Transluceny Screening
76814 26 Each additional fetus #
76815 26 Limited Ultrasound, (AFI, Viability, Fetal or Placenta Location)
76816 26 Follow-up/Repeat Ultrasound #
76817 26 Transvaginal OB (Cervical Length)
76856 26 Pelvic, GYN, Complete
76857 26 Pelvic, GYN, Limited or Follow-up (eg follicles)
76830 26 Transvaginal GYN
76700 26 Abdominal, Complete
76705 26 Abdominal, Limited (single organ, quadrant, follow-up)
76820 26 Doppler, Umbilical Cord, Initial or Repeat #
76821 26 Doppler, MCA, Initial or Repeat #
76825 26 Fetal Echocardiography, Initial #
76826 26 Fetal Echocardiography, Repeat #
76827 26 Fetal Cardiac Doppler, Complete #
76828 26 Fetal Cardiac Doppler, Repeat #
93325 26 Color Flow Mapping, when clinically indicated
76376 26 3 D Enhancement, when clinically indicated
93976 26 Uterine Artery Doppler
36460/
76941
26 Intrauterine Transfusion w/ US Guidance
59866/
76942
26 Multifetal Reduction w/ US Guidance
LABORATORY & MISCELLANEOUS PROCEDURES
57170 Diaphragm Fitting
59820 Dilation and Curettage (1st Trimester)
59821 Dilation and Curettage (2nd Trimester)
59412 External Cephalic Versions
82120/
83986
58300
Fem Exam (Amines, Vaginal Fluid, Qualitative and PH, Body Fluid)
Insertion of IUD
J7302
IUD Supply 5 Year
J7300
IUD Supply 10 Year
57160 Pessary Fitting
A4561
Pessary Supply (Rubber, any type)
A4562
Pessary Supply (Non-Rubber, any type)
59200 Placement of Cervical Dilators, Laminaria
99070 Laminaria Supplies #
59899 Removal of Cervical Cerclage (no anesthesia)
87210 Wet Mount Prep
10180 Wound I & D
S A M P L E
NURSING PROCEDURES
90772 Administration of Injection (Sub Q or IM)
J0704
Betamethasone, Number of Units______
90746 Injection of Hepatitis B Vaccine
90658 Injection of Influenza Vaccine (Whole Virus)
99211 Nursing Visit
90772/
J2790
Rhesus Immune Globulin Injection
99000 Specimen Collection/Handling (Office to Laboratory)
36415 Venipuncture (Routine)
MEDICAL NUTRITION THERAPY (Non-Physician)
97802 Initial Assessment, each 15 minutes #_________
97803 Re-assessment, each 15 minutes #_________
*Check with your payers to ensure reimbursement for these codes prior to usage.
TELEPHONE CALLS (Physician to patient or professionals)
99371 Simple or Brief Call
99372 Intermediate Call
99373 Complex or Lengthy Call
*Check with your payers to ensure reimbursement for these codes prior to usage.
Return visit:____________ weeks--____________ weeks or____________ days WITH____________ Same provider____________ Other provider:____________
Schedule other consultation:____________ IN____________ weeks or____________ days
Schedule ultrasound:____________ weeks or____________ days LMP:_____/_____/_____
FOR
_____________size < dates __________ size> dates __________ suspected IUGR __________ genetic ultrasound __________ dating _____________ follow-up for anomaly
_____________multiple gestation _________ cervical length _________ BPP _________ Other: ________________________________________
Provider Signature:_____________________________________________
SMFM Outpatient Encounter Form Copyright © 2007 Society for Maternal-Fetal Medicine 409 12th Street, SW, Washington, DC 20024-2188 ITEM 005

DX ICD-9 CODE DESCRIPTION DX ICD-9 CODE DESCRIPTION DX ICD-9 CODE DESCRIPTION
AMNIOTIC FLUID
658.03 Oligohydramnios
657.03 Polyhydramnios
658.13 PROM
658.23 PPROM
CARDIAC DISORDERS
648.53 Congenital Heart Disease
Specify:
648.63 Other Cardiac Disease
Specify:
CERVIAL/UTERINE PROBLEMS
654.63 Cervical Change
654.53 Cervical Incompetence
654.03 Congenital Uterine Anomaly
654.13 Uterine Leiomyomata
654.43/ 621.5 Uterine Synechiae
CNS ANOMALY
655.03 Agenesis of the Corpus Callosum
655.03 Anencephaly
655.03 Choroid Plexus Cysts
655.03 Encephalocele
655.03 Holoprosencephaly
655.03 Hydrocephaly
655.03 Microcephaly
655.03 Spina Bifida w/ Hydrocephalus
655.03 Spina Bifida w/o Hydrocephalus
CONGENITAL ANOMALIES
655.13 Fetal Chromosomal Abnormality
655.93 Known/Suspected, Unspecified
CONNECTIVE TISSUE
648.93/ 710.0 Lupus Erythematosus
648.73/ 714.0 Rheumatoid Arthritis
EARLY PREGNANCY
631 Blighted Ovum
634.92 Complete Abortion
633.XX
Ectopic Pregnancy
Specify:
646.33 Habitual Aborter (HX 3 SAB’s)
630 Hydatidform Mole
643.03 Hyperemesis, Mild
643.13 Hyperemesis, Severe
643.23 Hyperemesis>22 wks Gestation
634.91 Incomplete Abortion
632 Missed Abortion
640.03 Threatened Abortion
ENDOCRINE DISORDERS
648.03/ 250.XX Diabetes Mellitus (pre-pregnancy)
Specify:
648.83 Gestational Diabetes
648.13/ 242.9 Thyroid Disease (Hyperthyroidism)
648.13/ 244.9 Thyroid Disease (Hypothyroidism)
FETAL GROWTH PROBLEMS
656.53 Intrauterine Growth Restriction
656.63 Macrosomia
FETAL NON-CNS ANOMALIES
CARDIAC
655.83 Ebstein’s Anomaly
655.83 Echogenic Focus Heart (Non-specific)
655.83 Endocardial Cushion Defect (unspecified)
659.73 Fetal Arrhythmia
655.83 Hypoplastic Left Heart
655.83 Non-specific Congenital Heart
655.83 Tetralogy of Fallot
655.83 Ventricular Septal Defect
EXTREMITIES
655.83 Club foot
655.83 Polydactyly
655.83 Short Lower Extremities
655.83 Short Upper Extremities
FACE
655.83 Cleft Lip, Bilateral, Complete
655.83 Cleft Lip, Unilateral, Complete
655.83 Cleft Lip and Palate, Unspecified
GASTROINTESTINAL
655.83 Diaphragmatic Hernia
655.83 Duodenal Atresia
655.83 Echogenic Focus Bowel (Non-specific)
655.83 Esophageal Atresia
655.83 Gastroschisis
655.83 Omphalocele
655.83 Small Bowel Obstruction
FETAL NON-CNS ANOMALIES
CONTINUED
HYDROPS
653.73 Immune Hydrops Fetalis
653.73 Non-Immune Hydrops Fetalis
PULMONARY
655.83 CAM (Cystic Adenomatoid Malform)
655.83 Pulmonary Sequestration
RENAL
655.83 Bladder Outlet Obstruction
655.83 Hydronephrosis
655.83 Infantile Polycystic Kidney Disease
655.83 Multicystic Renal Disease
655.83 Renal Agenesis
655.83 UPV Obstruction
FETAL PRESENTATION
652.23 Breech Presentation
652.13 Breech = Vertex (Successful Version)
652.23 Breech (Unsuccessful Version)
652.33 Transverse or Oblique Lie
GASTROINTESTINAL DISORDERS
648.93/ 574.00 Cholelithiasis w/ Cholesystitis
648.93/ 574.20 Cholelithiasis w/o Cholesystitis
646.73 Cholestasis of pregnancy
646.73 Fatty liver of pregnancy
648.93/ 577.0 Pancreatitis
HEMATOLOGIC DISORDERS
648.93/ 287.4 Alloimmune Thrombocytopenia
648.23/ 280.9 Anemia (Fe Deficiency)
648.23/ 282.60 Anemia (Sickle Cell)
646.83/ 795.79 Antiphospholipid syndrome
648.93/ 287.3 Autoimmune Thrombocytopenia
649.33 Coagulation Defect
656.23 Other Red Cell Alloimmunization
648.93/ 289.81 Protein C Deficiency
648.93/ 289.81 Protein S Deficiency
656.13 Rh Alloimmunization
HYPERTENSIVE DISORDERS
642.03 Benign Essential Hypertension
642.73 Chronic Hypertension w/ Superimposed PIH
642.63 Eclampsia
642.33 Gestational Hypertension
642.13 Hypertension Due to Renal Disease
642.43 Mild Pre-eclampsia
642.53 Severe Pre-eclampsia
INFECTIOUS COMPLICATIONS
648.93/ 462 Acute Pharyngitis
647.23/ 099.53 Chlamydia
646.63/ 595.9 Cystitis (unspecified)
647.63/ 054.9 Genital Herpes
647.13 Gonorrhea
647.63/ V08 HIV Infection, Asymptomatic
647.63/ 042 HIV Infection, Symptomatic
647.03 Syphilis
Specify:
648.93/ 465.9 Upper Respiratory Infection (non-specific)
646.63/ 616.0 Vulvovaginitis (unspecified)
MULTIPLE GESTATIONS
651.03/655.83 Conjoined Twins
651.13 Triplets
651.43 Trips w/fetal loss & retention of =>1
651.03 Twins
651.03/663.83 Twin-Twin Transfusion Syndrome
651.33 Twins w/ 1 IUFD
651.23 Quadruplets
651.53 Quads w/fetal loss & retention of =>1
651.93 Quints or >
NEUROLOGIC DISORDERS
649.43/ 345.10 Epilepsy
649.43/ 358.1 Myasthenia Gravis
OBSTETRICAL PROBLEMS
654.23 Previous C-section
644.03 PTL (>22 wks)
OTHER FETAL PROBLEMS
655.73 Decreased Fetal Movement
656.43 IUFD (>22 wks)
PLACENTAL PROBLEMS
641.23 Placental Abruption
667.00 Placenta Accreta
641.13 Placenta Previa w/ Bleeding
641.03 Placenta Previa w/o Bleeding
663.53 Vasa Previa
PREGNANCY COMPLICATIONS
646.83/ 789.04 Abdominal Pain (LLQ)
646.83/ 789.02 Abdominal Pain (LUQ)
646.83/ 789.03 Abdominal Pain (RLQ)
646.83/ 789.01 Abdominal Pain (RUQ)
648.73 Back or Joint Pain
Specify:
649.23 Bariatric Surgery Status
649.13/278.00 Obesity
649.13/278.01 Obesity, Morbid
649.53 Spotting
649.03/305.1 Tobacco Use
671.13 Varicose Veins of Vulva
PREGNANCY DATING
V23.83 First Preg at < 16 yrs of age at EDD
V23.9 High Risk Preg (requires add. code)
V22.2 Incidental Pregnancy
V23.7 Insufficient Prenatal Care
645.13 Post-term Pregnancy (40-42 wks)
V72.41 Pregnancy exam/test, neg results
V72.40 Pregnancy exam/test, unconfirmed
645.23 Prolonged Pregnancy (> 42 wks)
656.13/V07.2 Rh Prophylaxis
V28.3 Screening malformations, via U/S
V23.84 Sub. Preg at < 16 yrs of age at EDD
V22.0 Supervision of Normal 1st Pregnancy
V28.8 Uncertain Gestational Age
649.63 Uterine size-date discrepancy
PRENATAL/FEMALE GENETICS
V26.31 Testing Genetic Disease Carrier
V26.32 Other Genetic Testing
V26.33 Genetic Counseling
PRENATAL / HX DIAGNOSIS
646.83/ 796.5 Abnormal Maternal Serum Screen
659.63 AMA (multigravida 35 or >)
659.53 AMA (primigravida 35 or >)
655.23 Hereditary disease Affecting Fetus
Specify:
V13.21 Personal HX of Preterm Labor
V26.4 General Counseling and Advice
V26.4 Preconception Counsel w/o Testing
Specify:
V26.3 Preconception Counsel and Testing
Specify:
V23.41 Pregnancy with HX Preterm Labor
V23.49 Pregnancy with other Poor OB HX
655.83/ 793.X Previous Abnormal Ultrasound
Specify:
655.53 Suspected Fetal Damage Drugs
Specify:
655.63 Suspected Fetal Damage Radiation
Specify:
655.63 Suspected Fetal Damage Viruses
POSTPARTUM PROBLEMS
675.12 or 4 Breast Abscess
674.24 Disruption of Episiotomy
670.02 or 4 Endometritis
V25.02 Fit Diaphragm/Cervical Cap
V25.09 General Contraceptive Counseling
674.32 or 4 Infection/ Hematoma of Abdominal Wound
V25.1 Insert IUD
V25.43 Insert Norplant
675.22 or 4 Non-purulent Mastitis
V25.01 Oral Contraceptive Prescription
648.44 Postpartum Depression
V24.2 Routine Postpartum visit
PSYCHIATRIC DISORDERS
648.33 Drug Dependence
Specify:
648.43 Psychiatric Disorders
Specify:
PULMONARY DISORDERS
648.93/ 493.90 Asthma w/o Status Asthmaticus
648.93/ 277.0 Cystic Fibrosis
RENAL DISORDERS
646.23 Gestational Proteinuria
646.23 Unspecified Renal disease w/o Hypertension
UMBILICAL CORD
663.83 Single Umbilical Artery
OTHER
*The above ICD-9 codes end with a fifth digit of 3 which denotes antepartum care. Plese remember to change the fifth digit to 0, 1, 2, or 4 when applicable.

Patient Name:________________________________
DOB:_______________Acct:____________________
Referring Physician:_________________________
✓
2007 INPATIENT / OUTPATIENT HOSPITAL MATERNAL-FETAL SERVICE
DX LK CPT DESCRIPTION ✓ DX LK CPT DESCRIPTION
Inpatient Consultations (Phys Ref) time is bedside & pt’s floor / unit
Outpatient Consultations - time is face-to-face with patient
99251 Problem Focused (Straightforward) 20 minutes 99241 Problem Focused (Straightforward) 15 minutes
99252 Expanded Problem Focused (Straightforward) 40 minutes 99242 Expanded Problem Focused (Straightforward) 30 minutes
99253 Detailed (Low Complexity) 55 minutes 99243 Detailed (Low Complexity) 40 minutes
99254 Comprehensive (Moderate Complexity) 80 minutes 99244 Comprehensive (Moderate Complexity) 60 minutes
99255 Comprehensive (High Complexity) 110 minutes 99245 Comprehensive (High Complexity) 80 minutes
Hospital Admission - time is bedside & pt’s floor / unit
Observation care - no times established for Observation care
99221 Detailed (Straightforward Complexity) 30 minutes 99218 Detailed (Straightforward Complexity)
99222 Comprehensive (Moderate Complexity) 50 minutes 99219 Comprehensive (Moderate Complexity)
99223 Comprehensive (High Complexity) 70 minutes 99220 Comprehensive (High Complexity)
Hospital Discharge
99217 Observation Care Discharge
99238 Discharge Day
Observation or Inpatient Hospital Care - admit & discharge same day
99239 Extended Discharge ( > 30 min) 99234 Detailed (Straightforward Complexity)
99235 Comprehensive (Moderate Complexity
E/R Visit - no time established
99236 Comprehensive (High Complexity)
99281 Problem Focused (Straightforward)
Outpatient Visit (Established Patient) - Time is face-to-face with patient
99282 Expanded Problem Focused (Low Complexity) 99212 Problem Focused (Straightforward) 10 minutes
99283 Expanded Problem Focused (Moderate Complexity) 99213 Expanded Problem Focused (Low Complexity) 15 minutes
99284 Detailed (Moderate Comlexity) 99214 Detailed (Moderate Complexity) 25 minutes
99285 Comprehensive (High Complexity) 99215 Comprehensive (High Complexity) 40 minutes
Subsequent Inpatient Hospital Visits - time is bedside & pt’s floor / unit
If procedure performed the same day add -25 modifier Date Date Date Date Date Date Date
99231 Problem Focused (Straightforward) 15 minutes
99232 Expanded Problem Focused (Moderate) 25 minutes
99233 Detailed (High Complexity) 35 minutes
Critical Care Total Time______
Physician Standby, Total Time_______
99291 first 30-74 minutes 99360 each 30 minutes
99292 each additional 30 minutes
Fetal Assessment Testing
Date Date Date Date Date Date Date
59025-26 NST #
76815-26 Limited Ultrasound, (AFI, Viability, Fetal or Placenta Location)
76816-26 Repeat-F/U #
76818-26 Biophysical #
76819-26 BPP without NST #
Ultrasound, Echocardiography & Doppler Procedures
76801-26 Complete Scan < 14.0 weeks 76825-26 Fetal Echocardiography, Initial #
76802-26 Each additional fetus # 76826-26 Fetal Echocardiography, Repeat #
76805-26 Complete Scan > or = 14.0 weeks 76827-26 Fetal Cardiac Doppler, Initial #
76810-26 Each additional fetus # 76828-26 Fetal Cardiac Doppler, Repeat #
76811-26 Complete Scan + Detailed Fetal Anatomy 93325-26 Color Flow Mapping , when clinically indicated
76812-26 Each additional fetus # 76376-26 3 D Enhancement, when clinically indicated
76813-26 Nuchal Translucency Screening 93976-26 Uterine Artery Doppler
76814-26 Each additional fetus # 76856-26 Pelvic Ultrasound - GYN
76817-26 Transvaginal OB 76857-26 Limited Ultrasound - GYN
76820-26 Doppler, Umbilical Cord, Initial or Repeat # 76830-26 Transvaginal GYN
76821-26 Doppler, MCA, Initial or Repeat #
Deliveries & Terminations
59400 Vaginal delivery global 58605 Tubal after vaginal
59409 Vaginal delivery only # 58611 Tubal w/ C-Section
59410 Vaginal w/ post care 59525 C-Section w/ hysterectomy
59510 C-Section global 59525-80 C-Section with hysterectomy, assistant
59514 C-Section only 59812 Incomplete AB, comp surg, any trimester
59514-22 C-Section - multifetal 59820 Missed AB, comp surg, 1st trimester
59515 C-Section w/ postpartum care 59821 Missed AB, comp surg, 2nd trimester
59515-22 C-Section w/ postpartum care - multifetal 59830 Septic AB, completed surgically
59614-80 C-Section assistant 59840 Induced AB by D&C
59610 VBAC global 59841 Induced AB by D&E
59612 VBAC only 59855 Induced AB, vaginal suppository
59614 VBAC w/ postpartum care 59856 Induced AB, vag supp, w/ D&C or D&E
59618 Failed VBAC global 59857 Induced AB, vag supp, w/ hysterectomy
59620 Failed VBAC only 59866/ 76942-26 Multifetal reduction w/guidance
59622 Failed VBAC w/ postpartum care 59897 Fetal injection,including guidance
59620-80 Failed VBAC assistant
Procedures
S A M P L E
59000/ 76946-26 Amnio w/ guidance # 59200 Insertion of cervical dilator
59012/ 76941-26 Cordocentesis w/ guidance 59412 External cephalic version
36460/ 76941-26 Fetal Transfusion w/ guidance 59070 Transabdominal Amnioinfusion,including guidance
59320 Cerclage, vaginal 59001 Amniotic Fluid Reduction,including guidance
59325 Cerclage, abdominal *0021T Insertion of transcervical or transvaginal fetal oximery sensor
Fetal Surgeries
59074 Fetal Fluid Drainage,including guidance 59072 Fetal Umbilical Cord Occlusion,including guidance
59897 Unlisted Fetal Invasive Procedure,including guidance 59076 Fetal Shunt Procedures,including guidance

DX ICD-9 CODE DESCRIPTION DX ICD-9 CODE DESCRIPTION DX ICD-9 CODE DESCRIPTION
AMNIOTIC FLUID
658.0X Oligohydramnios
657.0X Polyhydramnios
658.1X PROM
658.2X PPROM
CARDIAC DISORDERS Maternal
648.5X Congenital Heart Disease
Specify:
648.6X Other Cardiac Disease
Specify:
CERVIAL/UTERINE PROBLEMS
654.6X Cervical Change
654.5X Cervical Incompetence
654.0X Congenital Uterine Anomaly
654.1X Uterine Leiomyomata
654.4X/ 621.5 Uterine Synechiae
CNS ANOMALY
655.0X/ 742.2 Agenesis of the Corpus Callosum
655.0X/ 740.0 Anencephaly
655.0X/ 742.4 Choroid Plexus Cysts
655.0X/ 742.0 Encephalocele
655.0X/ 742.2 Holoprosencephaly
655.0X/ 742.3 Hydrocephaly
655.0X/ 742.1 Microcephaly
655.0X/ 741.0X Spina Bifida w/ Hydrocephalus
655.0X/ 741.9X Spina Bifida w/o Hydrocephalus
CONGENITAL ANOMALIES
655.1X Fetal Chromosomal Abnormality
Specify:
655.9X Known/Suspected, Unspecified
CONNECTIVE TISSUE
648.9X/ 710.0 Lupus Erythematosus
648.7X/ 714.0 Rheumatoid Arthritis
EARLY PREGNANCY
631 Blighted Ovum
634.92 Complete Abortion
633.XX
Ectopic Pregnancy
Specify:
646.3X Habitual Aborter (HX 3 SAB’s)
630 Hydatidform Mole
643.0X Hyperemesis, Mild
643.1X Hyperemesis, Severe
643.2X Hyperemesis>22 wks Gestation
634.91 Incomplete Abortion
632 Missed Abortion
640.0X Threatened Abortion
ENDOCRINE DISORDERS
648.0X/ 250.XX Diabetes Mellitus (pre-pregnancy)
Specify:
648.8X Gestational Diabetes
648.1X/ 242.9 Thyroid Disease (Hyperthyroidism)
648.1X/ 244.9 Thyroid Disease (Hypothyroidism)
FETAL GROWTH PROBLEMS
656.5X Intrauterine Growth Restriction
656.6X Macrosomia
FETAL NON-CNS ANOMALIES
CARDIAC
655.8X/ 746.2 Ebstein’s Anomaly
655.8X/ 793.2 Echogenic Focus Heart (Non-specific)
655.8X/ 745.60 Endocardial Cushion Defect (unspecified)
659.7X Fetal Arrhythmia
655.8X/ 746.7 Hypoplastic Left Heart
655.8X/ 746.9 Non-specific Congenital Heart
655.8X/ 745.2 Tetralogy of Fallot
655.8X/ 745.4 Ventricular Septal Defect
EXTREMITIES
655.8X/ 754.70 Club foot
655.8X/ 755.00 Polydactyly
655.8X/ 755.30 Short Lower Extremities
655.8X/ 755.20 Short Upper Extremities
FACE
655.8X/ 749.13 Cleft Lip, Bilateral, Complete
655.8X/ 749.11 Cleft Lip, Unilateral, Complete
655.8X/ 749.20 Cleft Lip and Palate, Unspecified
GASTROINTESTINAL
655.8X/ 756.6 Diaphragmatic Hernia
655.8X/ 750.3 Duodenal Atresia
655.8X/ 793.4 Echogenic Focus Bowel (Non-specific)
655.8X/ 750.3 Esophageal Atresia
655.8X/ 756.79 Gastroschisis
655.8X/ 756.79 Omphalocele
655.8X/ 751.1 Small Bowel Obstruction
FETAL NON-CNS ANOMALIES
CONTINUED
HYDROPS
653.7X Immune Hydrops Fetalis
653.7X Non-Immune Hydrops Fetalis
PULMONARY
655.83/ 748.4 CAM (Cystic Adenomatoid Malform)
655.83/ 748.69 Pulmonary Sequestration
RENAL
655.8X/ 753.6 Bladder Outlet Obstruction
655.8X/ 753.29 Hydronephrosis
655.8X/ 753.14 Infantile Polycystic Kidney Disease
655.8X/ 753.15 Multicystic Renal Disease
655.8X/ 753.0 Renal Agenesis
655.8X/ 753.21 UPV Obstruction
FETAL PRESENTATION
652.2X Breech Presentation
652.1X Breech = Vertex (Successful Version)
652.2X Breech (Unsuccessful Version)
652.3X Transverse or Oblique Lie
GASTROINTESTINAL DISORDERS
648.9X/ 574.00 Cholelithiasis w/ Cholesystitis
648.9X/ 574.20 Cholelithiasis w/o Cholesystitis
646.7X Cholestasis of pregnancy
646.7X Fatty liver of pregnancy
648.9X/ 577.0 Pancreatitis
HEMATOLOGIC DISORDERS
648.9X/ 287.4 Alloimmune Thrombocytopenia
648.2X/ 280.9 Anemia (Fe Deficiency)
648.2X/ 282.60 Anemia (Sickle Cell)
646.8X/ 795.79 Antiphospholipid Syndrome
648.9X/ 287.3 Autoimmune Thrombocytopenia
649.3X Coagulation Defect
656.2X Other Red Cell Alloimmunization
648.9X/ 289.81 Protein C Deficiency
648.9X/ 286.81 Protein S Deficiency
656.1X Rh Alloimmunization
HYPERTENSIVE DISORDERS
642.0X Benign Essential Hypertension
642.7X Chronic Hypertension w/ Superimposed PIH
642.6X Eclampsia
642.3X Gestational Hypertension
642.1X Hypertension Due to Renal Disease
642.4X Mild Pre-eclampsia
642.5X Severe Pre-eclampsia
INFECTIOUS COMPLICATIONS
648.9X/ 462 Acute Pharyngitis
647.2X/ 099.53 Chlamydia
646.6X/ 595.9 Cystitis (unspecified)
647.6X/ 054.9 Genital Herpes
647.1X Gonorrhea
647.6X/ V08 HIV Infection, Asymptomatic
647.6X/ 042 HIV Infection, Symptomatic
647.0X Syphilis
Specify:
648.9X/ 465.9 Upper Respiratory Infection (non-specific)
646.6X/ 616.0 Vulvovaginitis (unspecified)
MULTIPLE GESTATIONS
651.0X/655.8X Conjoined Twins
651.1X Triplets
651.4X Trips w/fetal loss & retention of =>1
651.0X/655.8X Twins
651.0X/663.8X Twin-Twin Transfusion Syndrome
651.3X Twins w/ 1 IUFD
651.2X Quadruplets
651.5X Quads w/fetal loss & retention of =>1
651.9X Quints or >
NEUROLOGIC DISORDERS
649.4X/ 345.10 Epilepsy
649.4X/ 358.1 Myasthenia Gravis
OBSTETRICAL PROBLEMS
654.2X Previous C-section
644.0X PTL (>22 wks)
OTHER FETAL PROBLEMS
655.7X Decreased Fetal Movement
656.4X IUFD (>22 wks)
PLACENTAL PROBLEMS
641.2X Placental Abruption
667.0X Placenta Accreta
641.1X Placenta Previa w/ Bleeding
641.0X Placenta Previa w/o Bleeding
663.5X Vasa Previa
PREGNANCY COMPLICATIONS
646.8X/ 789.04 Abdominal Pain (LLQ)
646.8X/ 789.02 Abdominal Pain (LUQ)
646.8X/ 789.03 Abdominal Pain (RLQ)
646.8X/ 789.01 Abdominal Pain (RUQ)
648.7X Back or Joint Pain
Specify:
649.2X Bariatric Surgery Status
649.1X/278.00 Obesity
649.1X/279.01 Obesity, Morbid
649.5X Spotting
649.0X/305.1 Tobacco Use
671.1X Varicose Veins of Vulva
INDICATIONS/COMPLICATIONS L&D
659.5X AMA Primigravida (35 or > @ EDD)
659.6X AMA Multigravida (35 or > @ EDD)
661.1X Arrest Active Phase
652.2X Breech Presentation
652.4X Brow/Face Presentation
653.1X Contracted Pelvis
663.1X Cord Around Neck w/ Compression
663.2X Cord Entanglement w/ Compression
663.3X Cord Entanglement w/o Compression
653.4X CPD
662.3X Delayed Delivery of Second Twin, etc.
660.7X Failed Forceps/Vacuum Extractor
659.0X Failed Mechanical Induction of Labor
659.1X Failed Medical or Unspecified Induction
660.6X Failed Trial of Labor
654.1X Fibroid(s) Obstructing Labor
659.3X Generalized Infection During Labor
647.6X Genital Herpes
659.4X Grand Multiparity
660.5X Locked Twins
656.6X Macrosomia
669.0X Maternal Distress
669.2X Maternal Hypotension Syndrome
652.6X Multigestation with Malpresentation
659.7X Non-Reasurring Fetal Tracing
641.2X Placental Abruption
641.1X Placental Previa, (with hemorrhage)
641.0X Placental Previa, (without hemorrhage)
645.1X Post-term Pregnancy(40-42 wks)
661.3X Precipitate Labor
658.1X Premature Rupture of Membranes
644.2X Preterm Labor with Delivery (42 wks)
658.2X Prolonged Rupture of Membranes
660.4X Shoulder Dystocia
663.4X Short Cord
652.3X Transverse or Oblique Presentation
652.0X Unstable Lie
663.8X Velamentous Insertion of Cord
PSYCHIATRIC DISORDERS
648.3X Drug Dependence
Specify:
648.4X Psychiatric Disorders
Specify:
PULMONARY DISORDERS
648.9X/ 493.90 Asthma w/o Status Asthmaticus
648.9X/ 277.0 Cystic Fibrosis
RENAL DISORDERS
646.2X Gestational Proteinuria
646.2X Unspecified Renal disease w/o Hypertension
UMBILICAL CORD
663.8X/ 747.5 Single Umbilical Artery
OTHER
* “X” indicates that an additional digit is required. Please refer to the AMA’s ICD-9 book for proper coding
SMFM Outpatient Encounter Form Copyright © 2006 Society for Maternal-Fetal Medicine 409 12th Street, SW, Washington, DC 20024-2188 Item #006