Obstetrics & Gynecology Medical Coding Guide
The Foundations of OB/GYN Coding
Evaluation & Management (E/M) in OB/GYN
OB/GYN coding is unique because it mixes "episodic" care (gynecology) with "global" care
(obstetrics).
Setting Common Codes Key Considerations
99202–99205 (New patient) Use Medical Decision Making (MDM) or Time (includ
Office/Outpatient
99212–99215 (Established) coordination).
99221–99223 (Initial hospital
Hospital care) Inpatient postpartum care is billed separately unless i
(Inpatient) 99231–99233 (Subsequent global package.
care)
99218–99220 (Initial
Observation Used for hyperemesis, preterm labor rule-outs.
observation)
Section 2: Gynecology Coding
A. Preventive Medicine (Annual Exams)
These codes are used for routine screenings (Pap smears, breast exams) with no complaint.
Code Description
99381–99387 Preventive visit, new patient (age-specific).
99391–99397 Preventive visit, established patient (age-specific).
G0101 HCPCS: Cervical or vaginal cancer screening (Pap) – used for Medicare/Medicaid.
Q0091 HCPCS: Screening Pap smear collection (usually billed with G0101).
Modifier -25: If a patient has a preventive visit and a problem-oriented visit (e.g., yeast
infection), append -25 to the E/M code.
B. Lesion Excision & Biopsy
, Code Description Coding Nuance
56605 Biopsy of vulva/ perineum (1 lesion) + 56606 for each additional lesio
57100 Biopsy of vaginal mucosa Simple, single.
57500 Biopsy of cervix (single or multiple) Punch biopsy.
57452 Colposcopy of cervix (without biopsy) Visualization only.
57455 Colposcopy with biopsy of cervix Includes the colposcopy.
57460 Colposcopy with LEEP (Loop Electrosurgical Excision Procedure) Includes colposcopy; use for CIN
57461 Colposcopy with LEEP (conization) Larger specimen.
C. Hysteroscopy & Endometrial Procedures
Code Description
58558 Hysteroscopy, diagnostic + surgical (e.g., polypectomy, D&C). Most common GYN surgical code.
58561 Hysteroscopy with removal of leiomyomata (myomectomy).
58120 Dilation and Curettage (D&C) without hysteroscopy.
58555 Hysteroscopy, diagnostic (only).
D. Laparoscopy & Laparotomy
Code Description
58661 Laparoscopy, surgical; with removal of adnexal structures (e.g., salpingectomy, oophorectomy
58670 Laparoscopy with fulguration of oviducts (tubal ligation).
58700 Salpingectomy (open), complete or partial.
58150 Total abdominal hysterectomy (TAH) with or without removal of tube(s)/ovary(ies).
58570–58573 Laparoscopic hysterectomy (TLH).
The Foundations of OB/GYN Coding
Evaluation & Management (E/M) in OB/GYN
OB/GYN coding is unique because it mixes "episodic" care (gynecology) with "global" care
(obstetrics).
Setting Common Codes Key Considerations
99202–99205 (New patient) Use Medical Decision Making (MDM) or Time (includ
Office/Outpatient
99212–99215 (Established) coordination).
99221–99223 (Initial hospital
Hospital care) Inpatient postpartum care is billed separately unless i
(Inpatient) 99231–99233 (Subsequent global package.
care)
99218–99220 (Initial
Observation Used for hyperemesis, preterm labor rule-outs.
observation)
Section 2: Gynecology Coding
A. Preventive Medicine (Annual Exams)
These codes are used for routine screenings (Pap smears, breast exams) with no complaint.
Code Description
99381–99387 Preventive visit, new patient (age-specific).
99391–99397 Preventive visit, established patient (age-specific).
G0101 HCPCS: Cervical or vaginal cancer screening (Pap) – used for Medicare/Medicaid.
Q0091 HCPCS: Screening Pap smear collection (usually billed with G0101).
Modifier -25: If a patient has a preventive visit and a problem-oriented visit (e.g., yeast
infection), append -25 to the E/M code.
B. Lesion Excision & Biopsy
, Code Description Coding Nuance
56605 Biopsy of vulva/ perineum (1 lesion) + 56606 for each additional lesio
57100 Biopsy of vaginal mucosa Simple, single.
57500 Biopsy of cervix (single or multiple) Punch biopsy.
57452 Colposcopy of cervix (without biopsy) Visualization only.
57455 Colposcopy with biopsy of cervix Includes the colposcopy.
57460 Colposcopy with LEEP (Loop Electrosurgical Excision Procedure) Includes colposcopy; use for CIN
57461 Colposcopy with LEEP (conization) Larger specimen.
C. Hysteroscopy & Endometrial Procedures
Code Description
58558 Hysteroscopy, diagnostic + surgical (e.g., polypectomy, D&C). Most common GYN surgical code.
58561 Hysteroscopy with removal of leiomyomata (myomectomy).
58120 Dilation and Curettage (D&C) without hysteroscopy.
58555 Hysteroscopy, diagnostic (only).
D. Laparoscopy & Laparotomy
Code Description
58661 Laparoscopy, surgical; with removal of adnexal structures (e.g., salpingectomy, oophorectomy
58670 Laparoscopy with fulguration of oviducts (tubal ligation).
58700 Salpingectomy (open), complete or partial.
58150 Total abdominal hysterectomy (TAH) with or without removal of tube(s)/ovary(ies).
58570–58573 Laparoscopic hysterectomy (TLH).
