Encounter Form (Cpsp Obstetrics/gynecology)
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1NAME
ID#
CPSP
ENCOUNTER FORM
PCP
Obstetrics/Gynecology
PCP PHONE #
GROUP
Provider Name:
COPAYS
Provider Number:
LMP:
Qty.
Code
Description
Qty.
Code
Description
Qty
Code
Description:
CPSP SERVICES
Z6500
Combined Assessments Total Minutes ________
MARK ONE OFFICE VISIT CODE
LABORATORY (con’t.)
99211
OV Level I, Established Pt.
87060
Culture, throat
Z6200
Initial Nutrition Assessment and ICP (30 Min.) x1 unit max.
99212
OV Level II, Established Pt.
88150
Pap Smear, Screening
Z6202
Initial Nutrition Assessment and ICP (15 min.) x6 units max.
99213
OV Level III, Established Pt.
82948
Blood Sugar, Fingerstick
Z6204
F/up Antepartum Nutrition Assessment (15 min.) x8
99214
OV Level IV, Established Pt.
86580
PPD
Z6206
F/up Antepartum Nutrition Assessment, Group (15 min)x4
99215
OV Level V, Established Pt.
81002
Urinalysis (office)
Z6208
Postpartum Nut. Assess/Treat/Interven. Indiv. (15 min) x4
MARK ONE OFFICE VISIT CODE
81025-25
UCG (office)
Z6210
Prenatal Vitamin/Mineral Supply - 300 day x1
Z1032
ZL
Initial OV < 16 weeks
87210
Wet Mount
Z6300
Initial Psychosocial Assessment and ICP (30 min) x1
Z1032
Initial OV > 16 weeks
ULTRASOUND/Dx TESTING
Z6302
Initial Psychosocial Assessment and ICP (15 min) x6
Z1034
Individual Antepartum OV
76805
ZS
Ultrasound - Complete
Z6304
F/up Psychosoc. Assess/Treat/Interven-Indiv.(15 min)x12
Z1036
Tenth Antepartum OV
76810
ZS
Ultrasound - Multiple Gestation
Z6306
F/up Psychosoc. Assess/Treat/Interven-Group(15min)x16
Z1038
Postpartum OV
76815
ZS
Ultrasound OB - Limited
Z6308
Postpartum Psychosocial Assessment/Treat/Inter/ICP
76816
ZS
Ultrasound OB - repeat or F/up
Z6400
Client Orientation (15 min) x8
BIOPSIES
56605
Biopsy, Vulva
59020
99
Fetal Contraction Stress Test
Z6402
Initial Health Ed Assess and ICP (30 min) x1
57100
Biopsy, Vaginal Mucosa
59025
99
Fetal Non-Stress Test
Z6404
Initial Health Ed Assess and ICP (15 min) x8
57500
Biopsy, Lesion, Cervix Uteri
Z6406
F/up Health Ed Assess.Treat/Interven - Indiv. (15 min) x8
I&D EXCISION / DESTRUCTION
Z6408
F/up Health Ed Assess.Treat/Interven - Group (15 min) x8
INJECTIONS/IV/IMMUNIZATIONS
11052
Pare/Curette - >.5cm
Z6410
Perinatal Education - Individual (15 min) x16
90742
Injection - RhoGam
11420
Exc Benign Lesion - <.5 cm
Z6412
Perinatal Education - Group (15 min) x16
90788
IM Injection - Antibiotic
19000
Aspiration Cyst - Breast
Z6414
Postpart Health Ed Assess/Treat/Interven-Group(15 min) x4
56420
I&D Bartholins Gland Abscess
Modifier ZQ: Family Planning Counseling
56501
Dest Lesions Vulva, Simple
SUPPLIES
PROVIDER
SINGLE MODIFIER
MULTIPLE MODIFIER
A45500604
Minor Surgery Tray
57061
Dest Lesions Vagina - Simple
Physician Assistant
AN
YU
LABORATORY
PROCEDURES
Certified Nurse Midwife
YQ
YR
25218
Collection
V26.1
Artificial Insemination
Certified Nurse Practitioner
YS
YT
25220
Handling
V50.2
Circumcision
87110-22
Culture, Chlamydia, by DNA
QTY.
CODE
WRITE-IN PROCEDURES:
QTY.
CODE
WRITE-IN PROCEDURES:
87110
Culture, Chlamydia not by
DNA
87070-22
Culture, GC, by DNA
87070
Culture, GC, not by DNA
DIAGNOSIS CODES: (MARK OR WRITE-IN 1 to 3 DIAGNOSIS CODES)
Code
Description
Code
Description
Code
Description
Code
Description
789.00
Abdominal Pain, Etiol. Unknown
617.3
Endometriosis - Pelvic
621.6
Malpositioned Uterus
131.01
Vaginitis, Trichomonas
795.0
Abnormal Pap
617.0
Endometriosis - Uterine
611.0
Mastitis
616.10
Vaginitis/Vulvovaginitis
637.91
Abortion, Incomplete
553.9
Enterocele without prolapse,
611.71
Mastodynia
671.13
Varicosity, Vulva
632
Abortion, Missed
Uterine
761.5
Multiple Pregnancy
112.1
Vulvovaginitis, Monilial
634.90
Abortion, Spontaneous
766.0
Exceptionally Large Baby
651.6
Multiple Pregnancy w/fetal loss
V28.2
Other screening based
640.03
Abortion, Threatened
656.6
Excessive Fetal Growth
& Retention of 1 or more fetus
on Amniocentesis
616.3
Abscess, Bartholin’s Gland
765.0
Extreme Immaturity
216
Nevus, Pigmented
765.1
Other Preterm Infants
617.0
Adenomyosis
779.9
Fetal Demise
653.0
Pelvic Deformity
460
Acute Nasopharyngitis
656.0
Fetal-Maternal Hemorrhage
657.03
Polyhydramnios
WRITE-IN DIAGNOSES:
477.9
Allergic Rhinitis
653.4
Fetal Pelvic Disproportion
451.9
Phlebitis/Thrombophlebitis
626.0
Amenorrhea
218.9
Fibroid Uterus
641.0
Placenta Previa w/o Hemorrhage
648.2
Anemia
619.1
Fistula, Vesico-Rectal
998.5
Post-op Wound Infection
280.9
Anemia, Iron Deficiency, Unspec.
276.6
Fluid Retention/Edema
V24.2
Postpartum Care
285.9
Anemia, Unspecified
V67.0
F/up Exam Following Surgery
766.2
Post-term Infant
300.00
Anxiety Reaction
676.60
Galactorrhea, Childbirth
642.40
Preeclampsia - Mild
631
Blighted Ovum
098.0
Gonorrhea
V22.1
Pregnancy, Normal/Prenatal Care
724.5
Back Pain, Unspecified
603
Hydatiform Mole
V23.9
Pregnancy, High Risk
616.2
Bartholin Cyst
784.0
Headache
633.9
Pregnancy, Ectopic, unspec.
611.72
Breast Lump/Mass
641.9
Unspec Antepartum
656.50
Pregnancy, Poor Fetal Growth
652.2
Breech Presentation
Hemorrhage
V61.7
Pregnancy, Unwanted
466.0
Bronchitis, Acute
640.9
Unspec. Hemorrhage
641.93
Pregnancy, Spotting
233.1
Carcinoma In Situ, Cervix Uterine
455.6
Hemorrhoids, Unspec without
Unspecified Site
180.9
Carcinoma, Cervix
complications
644.03
Premature Labor
182.0
Carcinoma, Endometrial
655.2
Hereditary Disease in Family
658.13
PROM
183.0
Carcinoma, Ovarian
Possibly Affecting Fetus
627.0
Premenopausal Bleeding
184.0
Carcinoma, Vaginal
054.9
Herpes Simplex
645.00
Prolonged Pregnancy
184.4
Carcinoma, Vulva
054.10
Herpes Genitalis-w/o complic.
698.1
Pruritus Vulvae
599.3
Caruncle, Urethra
054.11
Herpes Vulvovaginitis
316
Psychogenic Factors
622.7
Cervical Polyps
704.1
Hirsutism
affecting physical health
616.0
Cervicitis/Endocervicitis
042
HIV/AIDS
590.10
Pylonephritis, Acute
079.88
Chlamydia
614.1
Hydrosalpinx
618.0
Rectocele w/out prolapse, uterine
655.0
CNS Malformation
643.03
Hyperemesis Gravidarum
656.13
Rh Incompatibility
078.11
Condyloma Acuminata
642.03
Hypertention, Chronic
701.9
Skin Tag (Acrochrodon)
564.0
Constipation
642.93
Hypertension, Pregnancy
764.0
Slow Growth
620.2
Cyst, Ovarian
648.13
Hyperthyroidism - pregnancy
256.4
Stein-Leventhal Syndrome
610.1
Cystic Breast Disease
244.9
Hypothyroidism, Acquired
034.0
Strep Throat
618.0
Cystocele (Rectocele)
628.9
Infertility, Female
V28.0
Screening for Chromosomal Abn.
692.9
Dermatitis, Contact Unspecified
487
Influenza
by Amniocentesis
648.0
Diabetes Mellitus
764.9
IUGR
633.1
Tubal Pregnancy
250.00
Diabetes Mellitus, Type II, Adlt
656.4
Intrauterine Death
651.0
Twin Pregnancy
648.83
Diabetes, Gestational
644.03
Labor, Early
760.9
Unspecified Maternal Condition
250.01
Diabetes Type 1 - Insulin Dep.
624.9
Lesion Vulva/Other disorder
affecting the fetus/newborn
648.3
Drug Dependency
623.5
Leukorrhea
652.0
Unstable Lie
640.9
Early Pregnancy-Hemorrhage
701.0
Lichen Sclerosus
465.9
URI
Medi-Cal Managed Care
CPSP - Encounter Form
1/98
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