Well Woman Healthcheck Program - Diagnosis And Treatment Form

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Chart #
Well Woman HealthCheck Program – Diagnosis and Treatment Form
CERVICAL
Contractor/Location:
Provider:
Last Name:
First Name:
DOB:
/
/
DIAGNOSTIC PROCEDURES
FINAL DIAGNOSIS AND TREATMENT
Colposcopy
Date:
/
/
Status of Final Diagnosis
 with biopsy and ECC
 1 Work-up complete
 with biopsy
 2 Work-up pending
 without biopsy
 3 Lost to follow-up
Endocervical Curettage (alone)
Date:
/
/
 4 Work-up refused
Diagnostic LEEP
Date:
/
/
Final Diagnosis
Date:
/
/
Diagnostic Cold Knife Cone
Date:
/
/
 1 Normal/benign reaction/inflammation
Result
 2 CIN 1/mild dysplasia (biopsy diagnosis)
 3 CIN 2/moderate dysplasia (biopsy diagnosis)
1 Negative (WNL)
 4 CIN 3/severe dysplasia/CIS (Stage 0) (biopsy diagnosis)
2 Adenocarcinoma
 5 High grade SIL (biopsy diagnosis)
3 CIN I
 6 HPV/Condylomata/Atypia
4 CIN II
 7 Invasive cervical carcinoma (biopsy diagnosis)
5 CIN III/CIS
 8 Low grade SIL (biopsy diagnosis)
6 HSIL
7 Invasive carcinoma
Treatment Status
8 LSIL
 1 Treatment started
Date:
/
/
9 No tissue present
 2 Treatment payment source
 10 Not done – other/unknown reason
 11 Other nonmalignant abnormality (HPV/condyloma)
 3 Treatment pending
 12 Refused
 4 Lost to follow-up
 5 Treatment refused – Refusal form received 
Other Diagnostic Procedures
Date:
/
/
 6 Treatment not needed
Procedure
Treatment Options
Result
 1 Chemotherapy
Gynecological Consult/Visit
Date:
/
/
 2 Cone biopsy or conization
 3 Cryosurgery
99201 – 10 minutes
99204 – 45 minutes
 4 Hysterectomy
99202 – 20 minutes
99205 – 60 minutes (prior auth)
 5 Loop Electrode Excision Procedure (LEEP)
99203 – 30 minutes
Other:
 6 Radiation Therapy; Branch Therapy
Result
 7 Other (please specify):
 1 Negative (WNL)
 2 Infection/Inflammation/Reactive changes
 3 Not done – other/unknown reason
 4 Other abnormality
Notes/Recommendations
 5 Refused
 6 Unsatisfactory
Pap Test
Date:
/
/
Indication for Pap Test:
 1 Routine Pap test
 2 Breast record only
 3 DX referral
 57452 Colposcopy
 4 Pap test not done, proceeded directly to diagnostic of HPV test
 57454 Colposcopy with biopsy and endocervical curettage
 5 Patient under surveillance for a previous abnormal test
 57455 Colposcopy with biopsy
 57456 Colposcopy with endocervical curettage
Specimen Type
Pap Test Adequacy
 57461 Colposcopy with loop electrode conization
88142 Liquid
 Satisfactory
 57500 Biopsy, single or multiple, or local excision of lesion with or without
88164 Conventional
 Unsatisfactory
fulguration (separate procedure)
88175 Liquid and manual rescreening
 57520 Conization with or without fulguration, with or without dilation and
Pap Test Findings:
curettage, with or without repair, cold knife or laser
1 Negative for intraepithelial lesion or malignancy
 57522 Loop Electrode Excision Proceedure (LEEP)
2 Adenocarcinoma*
 58100 Endometrial sampling (biopsy) with or without endocervical
3 AGC (Atypical Glandular Cells)*
sampling (biopsy), without cervical dilation, any method (separate
4 ASC-H (Atypical squamous cells – cannot exclude HSIL)*
procedure)
5 ASC-US (Atypical squamous cells of undetermined significance)
 58110 Endometrial sampling (biopsy) performed in conjunction with
6 High grade SIL *
colposcopy (list separately in addition to code for primary
7 Low grade SIL / HPV
procedure)
8 Result pending
9 Non-program funded
Clinician’s Signature
 10 Squamous cell carcinoma *
Date:
HPV Test
 CPT Code - 87624
Date:
/
/
 Positive
Negative
Test not done
Rev. 01/15 6-WWH-011
White – Chart
Yellow – ADHS
Pink - Contractor

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