1|Page
Lower Abdominal Pain and Vaginal Bleeding in a 30-
Year-Old Woman - Complete Clinical Assessment,
Diagnosis, Treatment, SOAP Note, Patient Education
& Follow-Up (Walden University 2026)
Patient with genital warts has cryotherapy of an extensive number of
lesions on her mons pubis, labia and perineum. How is this procedure
coded? - ANSWER-56515
Rationale: The mons pubis and labia are part of the vulva. In the CPT®
Index look for Destruction/Lesion/Vulva/Extensive and you are referred
to 56515. The extensive code is reported due to the extensive number of
lesions. Verify the code in the numeric section.
What ICD-10-CM category is used to report the weeks of gestation of
pregnancy? - ANSWER-Z3A
Rationale: When a code from Chapter 15 is reported, an additional code
is reported to identify the specific week of the pregnancy. This is
reported from category Z3A Weeks of gestation.
Mrs. Jones, G1P0, is diagnosed with polyhydramnios and is scheduled
for amniocentesis to aspirate some of the excessive fluid from the
amniotic sac. The amniocentesis is performed under ultrasound
guidance. What is/are the code(s) for the procedure performed? -
ANSWER-59001
Rationale: In the CPT® Index look for
Amniocentesis/Therapeutic/Amniotic Fluid Reduction directing you to
code 59001. Read the parentheses in the code descriptor; this code
includes the ultrasound guidance. The ultrasound guidance is not
separately reported. 59000 is for diagnostic amniocentesis.
,2|Page
What ICD-10-CM code is reported for VIN III? - ANSWER-D07.1
Rationale: Look in the ICD-10-CM Alphabetic Index for VIN - See
Neoplasia, intraepithelial, vulva. Look in the Alphabetic Index for
Neoplasia/vulva/grade III (severe dysplasia) referring you to D07.1.
Verify in the Tabular List. The Alphabetic Index listing for
Dysplasia/vulva/severe NEC also directs you to D07.1. VIN III is listed
as carcinoma in situ in the Tabular List.
The patient presents with a recurrent infection of the Bartholin's gland
which has previously been treated with antibiotics and I&D. At this visit
her gynecologist incises the cyst, draining the material from it and tacks
the edges of the cyst open creating an open pouch to prevent recurrence.
How is this procedure coded? - ANSWER-56440
Rationale: Marsupialization is a procedure where a scalpel is used to cut
an opening in the top of the abscess pocket. The leaflets created by this
procedure are pulled away from the pocket and attached to the
surrounding skin with stitches or glue. This creates an open pouch to
help prevent recurrence of the abscess. Look in the CPT® Index look for
Bartholin's Gland/Cyst/Marsupialization or
Marsupialization/Cyst/Bartholin's Gland directing you to code 56440.
Marsupialization of Bartholin's gland cyst is reported with CPT® code
56440.
A patient is seen for three extra visits during the third trimester of her
30-week pregnancy because of her history of pre-eclampsia during her
previous pregnancy which puts her at risk for a recurrence of the
problem during this pregnancy. No problems develop. What diagnosis
code(s) is/are reported for these three extra visits? - ANSWER-O09.893,
Z3A.30
Rationale: Because the patient had pre-eclampsia in her previous
pregnancy she is being monitored for three additional visits because she
is at a high risk of getting pre-eclampsia during this current pregnancy.
Due to the patient being high-risk, she will not be coming in for
supervision of a normal pregnancy, eliminating Z34.83. Code O14.03 is
, 3|Page
incorrect because she is just being monitored for possible pre-eclampsia.
O09.893 is used for supervision of pregnancy of other high risk. Look in
the ICD-10-CM Alphabetic Index for Pregnancy/supervision of/high-
risk/due to (history of)/specified NEC directing you to O09.89-. In the
Tabular List a 7 thcharacter is needed to indicate the trimester. Report
code O09.893 for the third trimester. Instructional note in the beginning
of Chapter 15 indicates a code from Z3A is reported with the pregnancy
codes. The weeks of pregnancy is 30 weeks. Look in the Alphabetic
Index for Pregnancy/weeks of gestation/30 weeks and you are directed
to Z3A.30. Verify in the Tabular List.
A pregnant patient presents to the ED with bleeding, cramping, and
concerns of loss of tissue and material per vagina. On examination, the
physician discovers an open cervical os with no products of conception
seen. He tells the patient she has had an abortion. What type of abortion
has she had? - ANSWER-Spontaneous
Rationale: There is no indication this was an induced abortion. A missed
abortion does not occur with passage of material and tissue; it is silent,
meaning that the body does not recognize the pregnancy loss or expel
the pregnancy tissue. This case is considered a spontaneous abortion or
miscarriage.
What ICD-10-CM category is used to report the weeks of gestation of
pregnancy? - ANSWER-Z3A
Rationale: When a code from Chapter 15 is reported, an additional code
is reported to identify the specific week of the pregnancy. This is
reported from category Z3A Weeks of gestation.
A diabetic woman delivered her child and now returns to obstetrician's
office for follow up. She has had type 1 diabetes controlled with insulin
for most of her life. Her obstetrician will monitor her closely for several
weeks to be sure her pregnancy does not cause her permanent problems.
What diagnosis code is used for her visit 2 weeks after her delivery? -
ANSWER-O24.03
Lower Abdominal Pain and Vaginal Bleeding in a 30-
Year-Old Woman - Complete Clinical Assessment,
Diagnosis, Treatment, SOAP Note, Patient Education
& Follow-Up (Walden University 2026)
Patient with genital warts has cryotherapy of an extensive number of
lesions on her mons pubis, labia and perineum. How is this procedure
coded? - ANSWER-56515
Rationale: The mons pubis and labia are part of the vulva. In the CPT®
Index look for Destruction/Lesion/Vulva/Extensive and you are referred
to 56515. The extensive code is reported due to the extensive number of
lesions. Verify the code in the numeric section.
What ICD-10-CM category is used to report the weeks of gestation of
pregnancy? - ANSWER-Z3A
Rationale: When a code from Chapter 15 is reported, an additional code
is reported to identify the specific week of the pregnancy. This is
reported from category Z3A Weeks of gestation.
Mrs. Jones, G1P0, is diagnosed with polyhydramnios and is scheduled
for amniocentesis to aspirate some of the excessive fluid from the
amniotic sac. The amniocentesis is performed under ultrasound
guidance. What is/are the code(s) for the procedure performed? -
ANSWER-59001
Rationale: In the CPT® Index look for
Amniocentesis/Therapeutic/Amniotic Fluid Reduction directing you to
code 59001. Read the parentheses in the code descriptor; this code
includes the ultrasound guidance. The ultrasound guidance is not
separately reported. 59000 is for diagnostic amniocentesis.
,2|Page
What ICD-10-CM code is reported for VIN III? - ANSWER-D07.1
Rationale: Look in the ICD-10-CM Alphabetic Index for VIN - See
Neoplasia, intraepithelial, vulva. Look in the Alphabetic Index for
Neoplasia/vulva/grade III (severe dysplasia) referring you to D07.1.
Verify in the Tabular List. The Alphabetic Index listing for
Dysplasia/vulva/severe NEC also directs you to D07.1. VIN III is listed
as carcinoma in situ in the Tabular List.
The patient presents with a recurrent infection of the Bartholin's gland
which has previously been treated with antibiotics and I&D. At this visit
her gynecologist incises the cyst, draining the material from it and tacks
the edges of the cyst open creating an open pouch to prevent recurrence.
How is this procedure coded? - ANSWER-56440
Rationale: Marsupialization is a procedure where a scalpel is used to cut
an opening in the top of the abscess pocket. The leaflets created by this
procedure are pulled away from the pocket and attached to the
surrounding skin with stitches or glue. This creates an open pouch to
help prevent recurrence of the abscess. Look in the CPT® Index look for
Bartholin's Gland/Cyst/Marsupialization or
Marsupialization/Cyst/Bartholin's Gland directing you to code 56440.
Marsupialization of Bartholin's gland cyst is reported with CPT® code
56440.
A patient is seen for three extra visits during the third trimester of her
30-week pregnancy because of her history of pre-eclampsia during her
previous pregnancy which puts her at risk for a recurrence of the
problem during this pregnancy. No problems develop. What diagnosis
code(s) is/are reported for these three extra visits? - ANSWER-O09.893,
Z3A.30
Rationale: Because the patient had pre-eclampsia in her previous
pregnancy she is being monitored for three additional visits because she
is at a high risk of getting pre-eclampsia during this current pregnancy.
Due to the patient being high-risk, she will not be coming in for
supervision of a normal pregnancy, eliminating Z34.83. Code O14.03 is
, 3|Page
incorrect because she is just being monitored for possible pre-eclampsia.
O09.893 is used for supervision of pregnancy of other high risk. Look in
the ICD-10-CM Alphabetic Index for Pregnancy/supervision of/high-
risk/due to (history of)/specified NEC directing you to O09.89-. In the
Tabular List a 7 thcharacter is needed to indicate the trimester. Report
code O09.893 for the third trimester. Instructional note in the beginning
of Chapter 15 indicates a code from Z3A is reported with the pregnancy
codes. The weeks of pregnancy is 30 weeks. Look in the Alphabetic
Index for Pregnancy/weeks of gestation/30 weeks and you are directed
to Z3A.30. Verify in the Tabular List.
A pregnant patient presents to the ED with bleeding, cramping, and
concerns of loss of tissue and material per vagina. On examination, the
physician discovers an open cervical os with no products of conception
seen. He tells the patient she has had an abortion. What type of abortion
has she had? - ANSWER-Spontaneous
Rationale: There is no indication this was an induced abortion. A missed
abortion does not occur with passage of material and tissue; it is silent,
meaning that the body does not recognize the pregnancy loss or expel
the pregnancy tissue. This case is considered a spontaneous abortion or
miscarriage.
What ICD-10-CM category is used to report the weeks of gestation of
pregnancy? - ANSWER-Z3A
Rationale: When a code from Chapter 15 is reported, an additional code
is reported to identify the specific week of the pregnancy. This is
reported from category Z3A Weeks of gestation.
A diabetic woman delivered her child and now returns to obstetrician's
office for follow up. She has had type 1 diabetes controlled with insulin
for most of her life. Her obstetrician will monitor her closely for several
weeks to be sure her pregnancy does not cause her permanent problems.
What diagnosis code is used for her visit 2 weeks after her delivery? -
ANSWER-O24.03
