Client Name
*
First Name
Last Name
Pregnant?
Yes (Provide pregnancy information below)
No
Trimester
N/A
First
Second
Third
Weeks of Gestation
Date
MM
DD
YYYY
Location
Office
Home
Hospital
Procedure
99385 New Preventative 18-39 (Annual)
99386 New Preventative 40-64 (Annual)
99395 Established Preventative 18-39 (Annual)
99396 Established Preventative 40-64 (Annual)
99401 Counseling - 15 Min.
99402 Counseling - 30 Min.
99403 Counseling - 45 Min.
99404 Counseling - 60 Min.
58300 IUD Insert
58301 IUD Remove
J7300 IUD 00 Copper
J7302 IUD 02 Mirena
88150 Pap
Q0091 Pap Collection
99000 Specimen/Lab Handling
87210 Wet Mount
36415 Venipuncture
90384 Injection
J2790 Rhogam
Diagnostic Code 1
648.23 Anemia
795.01 Abnormal pap
611.72 Breast lump
V13.22 Cervical dysplasia, Hx
099.41 Chlamydia cult
V25.40 Contraceptive surveil unspec
625.3 Dysmenorrhea
V25.09 GYN counsl - contraceptive mgt
V26.33 Genetic counseling
V26.32 Genetic testing
054.10 Genital herpes
098.89 Gonorrhea cult
V72.31 GYN exam
455.6 Hemorrhoids
054.9 Herpes simplex
053.9 Herpes zoster
795.05 HPV
564.1 IBS
V06.8 Immunization, combination
V81.6 Infertility screening
996.65 IUD infect/inflammation
V25.12 IUD removal
V25.13 IUD removal and reinsertion
V25.42 IUD surveillance
611.0 Mastitis
626.2 Menstruation, excessive
626.6 Metrorrhagia
278.00 Obesity
V25.01 Oral contraception
278.02 Overweight
V72.32 Pap to conf normal after initial abnormal pap
V76.2 Pap smear, routine
V26.49 Procreative counseling
V74.5 STD screen
131.01 Trichomonal vulvovaginitis
V72.40 Unconfirmed pregnancy
599 UTI (or 646.63)
41.9 Vag infection
614.9 Vaginitis
616.1 Vaginitis and vulvovaginitis
V70.0 Well woman annual
V79.0 Screening for Depression
Diagnostic Code 2
648.23 Anemia
795.01 Abnormal pap
611.72 Breast lump
V13.22 Cervical dysplasia, Hx
099.41 Chlamydia cult
V25.40 Contraceptive surveil unspec
625.3 Dysmenorrhea
V25.09 GYN counsl - contraceptive mgt
V26.33 Genetic counseling
V26.32 Genetic testing
054.10 Genital herpes
098.89 Gonorrhea cult
V72.31 GYN exam
455.6 Hemorrhoids
054.9 Herpes simplex
053.9 Herpes zoster
795.05 HPV
564.1 IBS
V06.8 Immunization, combination
V81.6 Infertility screening
996.65 IUD infect/inflammation
V25.12 IUD removal
V25.13 IUD removal and reinsertion
V25.42 IUD surveillance
611.0 Mastitis
626.2 Menstruation, excessive
626.6 Metrorrhagia
278.00 Obesity
V25.01 Oral contraception
278.02 Overweight
V72.32 Pap to conf normal after initial abnormal pap
V76.2 Pap smear, routine
V26.49 Procreative counseling
V74.5 STD screen
131.01 Trichomonal vulvovaginitis
V72.40 Unconfirmed pregnancy
599 UTI (or 646.63)
41.9 Vag infection
614.9 Vaginitis
616.1 Vaginitis and vulvovaginitis
V70.0 Well woman annual
V79.0 Screening for Depression
Diagnostic Code 3
648.23 Anemia
795.01 Abnormal pap
611.72 Breast lump
V13.22 Cervical dysplasia, Hx
099.41 Chlamydia cult
V25.40 Contraceptive surveil unspec
625.3 Dysmenorrhea
V25.09 GYN counsl - contraceptive mgt
V26.33 Genetic counseling
V26.32 Genetic testing
054.10 Genital herpes
098.89 Gonorrhea cult
V72.31 GYN exam
455.6 Hemorrhoids
054.9 Herpes simplex
053.9 Herpes zoster
795.05 HPV
564.1 IBS
V06.8 Immunization, combination
V81.6 Infertility screening
996.65 IUD infect/inflammation
V25.12 IUD removal
V25.13 IUD removal and reinsertion
V25.42 IUD surveillance
611.0 Mastitis
626.2 Menstruation, excessive
626.6 Metrorrhagia
278.00 Obesity
V25.01 Oral contraception
278.02 Overweight
V72.32 Pap to conf normal after initial abnormal pap
V76.2 Pap smear, routine
V26.49 Procreative counseling
V74.5 STD screen
131.01 Trichomonal vulvovaginitis
V72.40 Unconfirmed pregnancy
599 UTI (or 646.63)
41.9 Vag infection
614.9 Vaginitis
616.1 Vaginitis and vulvovaginitis
V70.0 Well woman annual
V79.0 Screening for Depression
Diagnostic Code 4
648.23 Anemia
795.01 Abnormal pap
611.72 Breast lump
V13.22 Cervical dysplasia, Hx
099.41 Chlamydia cult
V25.40 Contraceptive surveil unspec
625.3 Dysmenorrhea
V25.09 GYN counsl - contraceptive mgt
V26.33 Genetic counseling
V26.32 Genetic testing
054.10 Genital herpes
098.89 Gonorrhea cult
V72.31 GYN exam
455.6 Hemorrhoids
054.9 Herpes simplex
053.9 Herpes zoster
795.05 HPV
564.1 IBS
V06.8 Immunization, combination
V81.6 Infertility screening
996.65 IUD infect/inflammation
V25.12 IUD removal
V25.13 IUD removal and reinsertion
V25.42 IUD surveillance
611.0 Mastitis
626.2 Menstruation, excessive
626.6 Metrorrhagia
278.00 Obesity
V25.01 Oral contraception
278.02 Overweight
V72.32 Pap to conf normal after initial abnormal pap
V76.2 Pap smear, routine
V26.49 Procreative counseling
V74.5 STD screen
131.01 Trichomonal vulvovaginitis
V72.40 Unconfirmed pregnancy
599 UTI (or 646.63)
41.9 Vag infection
614.9 Vaginitis
616.1 Vaginitis and vulvovaginitis
V70.0 Well woman annual
V79.0 Screening for Depression
Date
MM
DD
YYYY
Location
Office
Home
Hospital
Procedure
99385 New Preventative 18-39 (Annual)
99386 New Preventative 40-64 (Annual)
99395 Established Preventative 18-39 (Annual)
99396 Established Preventative 40-64 (Annual)
99401 Counseling - 15 Min.
99402 Counseling - 30 Min.
99403 Counseling - 45 Min.
99404 Counseling - 60 Min.
58300 IUD Insert
58301 IUD Remove
J7300 IUD 00 Copper
J7302 IUD 02 Mirena
88150 Pap
Q0091 Pap Collection
99000 Specimen/Lab Handling
87210 Wet Mount
36415 Venipuncture
90384 Injection
J2790 Rhogam
Diagnostic Code 1
648.23 Anemia
795.01 Abnormal pap
611.72 Breast lump
V13.22 Cervical dysplasia, Hx
099.41 Chlamydia cult
V25.40 Contraceptive surveil unspec
625.3 Dysmenorrhea
V25.09 GYN counsl - contraceptive mgt
V26.33 Genetic counseling
V26.32 Genetic testing
054.10 Genital herpes
098.89 Gonorrhea cult
V72.31 GYN exam
455.6 Hemorrhoids
054.9 Herpes simplex
053.9 Herpes zoster
795.05 HPV
564.1 IBS
V06.8 Immunization, combination
V81.6 Infertility screening
996.65 IUD infect/inflammation
V25.12 IUD removal
V25.13 IUD removal and reinsertion
V25.42 IUD surveillance
611.0 Mastitis
626.2 Menstruation, excessive
626.6 Metrorrhagia
278.00 Obesity
V25.01 Oral contraception
278.02 Overweight
V72.32 Pap to conf normal after initial abnormal pap
V76.2 Pap smear, routine
V26.49 Procreative counseling
V74.5 STD screen
131.01 Trichomonal vulvovaginitis
V72.40 Unconfirmed pregnancy
599 UTI (or 646.63)
41.9 Vag infection
614.9 Vaginitis
616.1 Vaginitis and vulvovaginitis
V70.0 Well woman annual
V79.0 Screening for Depression
Diagnostic Code 2
648.23 Anemia
795.01 Abnormal pap
611.72 Breast lump
V13.22 Cervical dysplasia, Hx
099.41 Chlamydia cult
V25.40 Contraceptive surveil unspec
625.3 Dysmenorrhea
V25.09 GYN counsl - contraceptive mgt
V26.33 Genetic counseling
V26.32 Genetic testing
054.10 Genital herpes
098.89 Gonorrhea cult
V72.31 GYN exam
455.6 Hemorrhoids
054.9 Herpes simplex
053.9 Herpes zoster
795.05 HPV
564.1 IBS
V06.8 Immunization, combination
V81.6 Infertility screening
996.65 IUD infect/inflammation
V25.12 IUD removal
V25.13 IUD removal and reinsertion
V25.42 IUD surveillance
611.0 Mastitis
626.2 Menstruation, excessive
626.6 Metrorrhagia
278.00 Obesity
V25.01 Oral contraception
278.02 Overweight
V72.32 Pap to conf normal after initial abnormal pap
V76.2 Pap smear, routine
V26.49 Procreative counseling
V74.5 STD screen
131.01 Trichomonal vulvovaginitis
V72.40 Unconfirmed pregnancy
599 UTI (or 646.63)
41.9 Vag infection
614.9 Vaginitis
616.1 Vaginitis and vulvovaginitis
V70.0 Well woman annual
V79.0 Screening for Depression
Diagnostic Code 3
648.23 Anemia
795.01 Abnormal pap
611.72 Breast lump
V13.22 Cervical dysplasia, Hx
099.41 Chlamydia cult
V25.40 Contraceptive surveil unspec
625.3 Dysmenorrhea
V25.09 GYN counsl - contraceptive mgt
V26.33 Genetic counseling
V26.32 Genetic testing
054.10 Genital herpes
098.89 Gonorrhea cult
V72.31 GYN exam
455.6 Hemorrhoids
054.9 Herpes simplex
053.9 Herpes zoster
795.05 HPV
564.1 IBS
V06.8 Immunization, combination
V81.6 Infertility screening
996.65 IUD infect/inflammation
V25.12 IUD removal
V25.13 IUD removal and reinsertion
V25.42 IUD surveillance
611.0 Mastitis
626.2 Menstruation, excessive
626.6 Metrorrhagia
278.00 Obesity
V25.01 Oral contraception
278.02 Overweight
V72.32 Pap to conf normal after initial abnormal pap
V76.2 Pap smear, routine
V26.49 Procreative counseling
V74.5 STD screen
131.01 Trichomonal vulvovaginitis
V72.40 Unconfirmed pregnancy
599 UTI (or 646.63)
41.9 Vag infection
614.9 Vaginitis
616.1 Vaginitis and vulvovaginitis
V70.0 Well woman annual
V79.0 Screening for Depression
Diagnostic Code 4
648.23 Anemia
795.01 Abnormal pap
611.72 Breast lump
V13.22 Cervical dysplasia, Hx
099.41 Chlamydia cult
V25.40 Contraceptive surveil unspec
625.3 Dysmenorrhea
V25.09 GYN counsl - contraceptive mgt
V26.33 Genetic counseling
V26.32 Genetic testing
054.10 Genital herpes
098.89 Gonorrhea cult
V72.31 GYN exam
455.6 Hemorrhoids
054.9 Herpes simplex
053.9 Herpes zoster
795.05 HPV
564.1 IBS
V06.8 Immunization, combination
V81.6 Infertility screening
996.65 IUD infect/inflammation
V25.12 IUD removal
V25.13 IUD removal and reinsertion
V25.42 IUD surveillance
611.0 Mastitis
626.2 Menstruation, excessive
626.6 Metrorrhagia
278.00 Obesity
V25.01 Oral contraception
278.02 Overweight
V72.32 Pap to conf normal after initial abnormal pap
V76.2 Pap smear, routine
V26.49 Procreative counseling
V74.5 STD screen
131.01 Trichomonal vulvovaginitis
V72.40 Unconfirmed pregnancy
599 UTI (or 646.63)
41.9 Vag infection
614.9 Vaginitis
616.1 Vaginitis and vulvovaginitis
V70.0 Well woman annual
V79.0 Screening for Depression
Date
MM
DD
YYYY
Location
Office
Home
Hospital
Procedure
99385 New Preventative 18-39 (Annual)
99386 New Preventative 40-64 (Annual)
99395 Established Preventative 18-39 (Annual)
99396 Established Preventative 40-64 (Annual)
99401 Counseling - 15 Min.
99402 Counseling - 30 Min.
99403 Counseling - 45 Min.
99404 Counseling - 60 Min.
58300 IUD Insert
58301 IUD Remove
J7300 IUD 00 Copper
J7302 IUD 02 Mirena
88150 Pap
Q0091 Pap Collection
99000 Specimen/Lab Handling
87210 Wet Mount
36415 Venipuncture
90384 Injection
J2790 Rhogam
Diagnostic Code 1
648.23 Anemia
795.01 Abnormal pap
611.72 Breast lump
V13.22 Cervical dysplasia, Hx
099.41 Chlamydia cult
V25.40 Contraceptive surveil unspec
625.3 Dysmenorrhea
V25.09 GYN counsl - contraceptive mgt
V26.33 Genetic counseling
V26.32 Genetic testing
054.10 Genital herpes
098.89 Gonorrhea cult
V72.31 GYN exam
455.6 Hemorrhoids
054.9 Herpes simplex
053.9 Herpes zoster
795.05 HPV
564.1 IBS
V06.8 Immunization, combination
V81.6 Infertility screening
996.65 IUD infect/inflammation
V25.12 IUD removal
V25.13 IUD removal and reinsertion
V25.42 IUD surveillance
611.0 Mastitis
626.2 Menstruation, excessive
626.6 Metrorrhagia
278.00 Obesity
V25.01 Oral contraception
278.02 Overweight
V72.32 Pap to conf normal after initial abnormal pap
V76.2 Pap smear, routine
V26.49 Procreative counseling
V74.5 STD screen
131.01 Trichomonal vulvovaginitis
V72.40 Unconfirmed pregnancy
599 UTI (or 646.63)
41.9 Vag infection
614.9 Vaginitis
616.1 Vaginitis and vulvovaginitis
V70.0 Well woman annual
V79.0 Screening for Depression
Diagnostic Code 2
648.23 Anemia
795.01 Abnormal pap
611.72 Breast lump
V13.22 Cervical dysplasia, Hx
099.41 Chlamydia cult
V25.40 Contraceptive surveil unspec
625.3 Dysmenorrhea
V25.09 GYN counsl - contraceptive mgt
V26.33 Genetic counseling
V26.32 Genetic testing
054.10 Genital herpes
098.89 Gonorrhea cult
V72.31 GYN exam
455.6 Hemorrhoids
054.9 Herpes simplex
053.9 Herpes zoster
795.05 HPV
564.1 IBS
V06.8 Immunization, combination
V81.6 Infertility screening
996.65 IUD infect/inflammation
V25.12 IUD removal
V25.13 IUD removal and reinsertion
V25.42 IUD surveillance
611.0 Mastitis
626.2 Menstruation, excessive
626.6 Metrorrhagia
278.00 Obesity
V25.01 Oral contraception
278.02 Overweight
V72.32 Pap to conf normal after initial abnormal pap
V76.2 Pap smear, routine
V26.49 Procreative counseling
V74.5 STD screen
131.01 Trichomonal vulvovaginitis
V72.40 Unconfirmed pregnancy
599 UTI (or 646.63)
41.9 Vag infection
614.9 Vaginitis
616.1 Vaginitis and vulvovaginitis
V70.0 Well woman annual
V79.0 Screening for Depression
Diagnostic Code 3
648.23 Anemia
795.01 Abnormal pap
611.72 Breast lump
V13.22 Cervical dysplasia, Hx
099.41 Chlamydia cult
V25.40 Contraceptive surveil unspec
625.3 Dysmenorrhea
V25.09 GYN counsl - contraceptive mgt
V26.33 Genetic counseling
V26.32 Genetic testing
054.10 Genital herpes
098.89 Gonorrhea cult
V72.31 GYN exam
455.6 Hemorrhoids
054.9 Herpes simplex
053.9 Herpes zoster
795.05 HPV
564.1 IBS
V06.8 Immunization, combination
V81.6 Infertility screening
996.65 IUD infect/inflammation
V25.12 IUD removal
V25.13 IUD removal and reinsertion
V25.42 IUD surveillance
611.0 Mastitis
626.2 Menstruation, excessive
626.6 Metrorrhagia
278.00 Obesity
V25.01 Oral contraception
278.02 Overweight
V72.32 Pap to conf normal after initial abnormal pap
V76.2 Pap smear, routine
V26.49 Procreative counseling
V74.5 STD screen
131.01 Trichomonal vulvovaginitis
V72.40 Unconfirmed pregnancy
599 UTI (or 646.63)
41.9 Vag infection
614.9 Vaginitis
616.1 Vaginitis and vulvovaginitis
V70.0 Well woman annual
V79.0 Screening for Depression
Diagnostic Code 4
648.23 Anemia
795.01 Abnormal pap
611.72 Breast lump
V13.22 Cervical dysplasia, Hx
099.41 Chlamydia cult
V25.40 Contraceptive surveil unspec
625.3 Dysmenorrhea
V25.09 GYN counsl - contraceptive mgt
V26.33 Genetic counseling
V26.32 Genetic testing
054.10 Genital herpes
098.89 Gonorrhea cult
V72.31 GYN exam
455.6 Hemorrhoids
054.9 Herpes simplex
053.9 Herpes zoster
795.05 HPV
564.1 IBS
V06.8 Immunization, combination
V81.6 Infertility screening
996.65 IUD infect/inflammation
V25.12 IUD removal
V25.13 IUD removal and reinsertion
V25.42 IUD surveillance
611.0 Mastitis
626.2 Menstruation, excessive
626.6 Metrorrhagia
278.00 Obesity
V25.01 Oral contraception
278.02 Overweight
V72.32 Pap to conf normal after initial abnormal pap
V76.2 Pap smear, routine
V26.49 Procreative counseling
V74.5 STD screen
131.01 Trichomonal vulvovaginitis
V72.40 Unconfirmed pregnancy
599 UTI (or 646.63)
41.9 Vag infection
614.9 Vaginitis
616.1 Vaginitis and vulvovaginitis
V70.0 Well woman annual
V79.0 Screening for Depression
Date
MM
DD
YYYY
Location
Office
Home
Hospital
Procedure
99385 New Preventative 18-39 (Annual)
99386 New Preventative 40-64 (Annual)
99395 Established Preventative 18-39 (Annual)
99396 Established Preventative 40-64 (Annual)
99401 Counseling - 15 Min.
99402 Counseling - 30 Min.
99403 Counseling - 45 Min.
99404 Counseling - 60 Min.
58300 IUD Insert
58301 IUD Remove
J7300 IUD 00 Copper
J7302 IUD 02 Mirena
88150 Pap
Q0091 Pap Collection
99000 Specimen/Lab Handling
87210 Wet Mount
36415 Venipuncture
90384 Injection
J2790 Rhogam
Diagnostic Code 1
648.23 Anemia
795.01 Abnormal pap
611.72 Breast lump
V13.22 Cervical dysplasia, Hx
099.41 Chlamydia cult
V25.40 Contraceptive surveil unspec
625.3 Dysmenorrhea
V25.09 GYN counsl - contraceptive mgt
V26.33 Genetic counseling
V26.32 Genetic testing
054.10 Genital herpes
098.89 Gonorrhea cult
V72.31 GYN exam
455.6 Hemorrhoids
054.9 Herpes simplex
053.9 Herpes zoster
795.05 HPV
564.1 IBS
V06.8 Immunization, combination
V81.6 Infertility screening
996.65 IUD infect/inflammation
V25.12 IUD removal
V25.13 IUD removal and reinsertion
V25.42 IUD surveillance
611.0 Mastitis
626.2 Menstruation, excessive
626.6 Metrorrhagia
278.00 Obesity
V25.01 Oral contraception
278.02 Overweight
V72.32 Pap to conf normal after initial abnormal pap
V76.2 Pap smear, routine
V26.49 Procreative counseling
V74.5 STD screen
131.01 Trichomonal vulvovaginitis
V72.40 Unconfirmed pregnancy
599 UTI (or 646.63)
41.9 Vag infection
614.9 Vaginitis
616.1 Vaginitis and vulvovaginitis
V70.0 Well woman annual
V79.0 Screening for Depression
Diagnostic Code 2
648.23 Anemia
795.01 Abnormal pap
611.72 Breast lump
V13.22 Cervical dysplasia, Hx
099.41 Chlamydia cult
V25.40 Contraceptive surveil unspec
625.3 Dysmenorrhea
V25.09 GYN counsl - contraceptive mgt
V26.33 Genetic counseling
V26.32 Genetic testing
054.10 Genital herpes
098.89 Gonorrhea cult
V72.31 GYN exam
455.6 Hemorrhoids
054.9 Herpes simplex
053.9 Herpes zoster
795.05 HPV
564.1 IBS
V06.8 Immunization, combination
V81.6 Infertility screening
996.65 IUD infect/inflammation
V25.12 IUD removal
V25.13 IUD removal and reinsertion
V25.42 IUD surveillance
611.0 Mastitis
626.2 Menstruation, excessive
626.6 Metrorrhagia
278.00 Obesity
V25.01 Oral contraception
278.02 Overweight
V72.32 Pap to conf normal after initial abnormal pap
V76.2 Pap smear, routine
V26.49 Procreative counseling
V74.5 STD screen
131.01 Trichomonal vulvovaginitis
V72.40 Unconfirmed pregnancy
599 UTI (or 646.63)
41.9 Vag infection
614.9 Vaginitis
616.1 Vaginitis and vulvovaginitis
V70.0 Well woman annual
V79.0 Screening for Depression
Diagnostic Code 3
648.23 Anemia
795.01 Abnormal pap
611.72 Breast lump
V13.22 Cervical dysplasia, Hx
099.41 Chlamydia cult
V25.40 Contraceptive surveil unspec
625.3 Dysmenorrhea
V25.09 GYN counsl - contraceptive mgt
V26.33 Genetic counseling
V26.32 Genetic testing
054.10 Genital herpes
098.89 Gonorrhea cult
V72.31 GYN exam
455.6 Hemorrhoids
054.9 Herpes simplex
053.9 Herpes zoster
795.05 HPV
564.1 IBS
V06.8 Immunization, combination
V81.6 Infertility screening
996.65 IUD infect/inflammation
V25.12 IUD removal
V25.13 IUD removal and reinsertion
V25.42 IUD surveillance
611.0 Mastitis
626.2 Menstruation, excessive
626.6 Metrorrhagia
278.00 Obesity
V25.01 Oral contraception
278.02 Overweight
V72.32 Pap to conf normal after initial abnormal pap
V76.2 Pap smear, routine
V26.49 Procreative counseling
V74.5 STD screen
131.01 Trichomonal vulvovaginitis
V72.40 Unconfirmed pregnancy
599 UTI (or 646.63)
41.9 Vag infection
614.9 Vaginitis
616.1 Vaginitis and vulvovaginitis
V70.0 Well woman annual
V79.0 Screening for Depression
Diagnostic Code 4
648.23 Anemia
795.01 Abnormal pap
611.72 Breast lump
V13.22 Cervical dysplasia, Hx
099.41 Chlamydia cult
V25.40 Contraceptive surveil unspec
625.3 Dysmenorrhea
V25.09 GYN counsl - contraceptive mgt
V26.33 Genetic counseling
V26.32 Genetic testing
054.10 Genital herpes
098.89 Gonorrhea cult
V72.31 GYN exam
455.6 Hemorrhoids
054.9 Herpes simplex
053.9 Herpes zoster
795.05 HPV
564.1 IBS
V06.8 Immunization, combination
V81.6 Infertility screening
996.65 IUD infect/inflammation
V25.12 IUD removal
V25.13 IUD removal and reinsertion
V25.42 IUD surveillance
611.0 Mastitis
626.2 Menstruation, excessive
626.6 Metrorrhagia
278.00 Obesity
V25.01 Oral contraception
278.02 Overweight
V72.32 Pap to conf normal after initial abnormal pap
V76.2 Pap smear, routine
V26.49 Procreative counseling
V74.5 STD screen
131.01 Trichomonal vulvovaginitis
V72.40 Unconfirmed pregnancy
599 UTI (or 646.63)
41.9 Vag infection
614.9 Vaginitis
616.1 Vaginitis and vulvovaginitis
V70.0 Well woman annual
V79.0 Screening for Depression
Date
MM
DD
YYYY
Location
Office
Home
Hospital
Procedure
99385 New Preventative 18-39 (Annual)
99386 New Preventative 40-64 (Annual)
99395 Established Preventative 18-39 (Annual)
99396 Established Preventative 40-64 (Annual)
99401 Counseling - 15 Min.
99402 Counseling - 30 Min.
99403 Counseling - 45 Min.
99404 Counseling - 60 Min.
58300 IUD Insert
58301 IUD Remove
J7300 IUD 00 Copper
J7302 IUD 02 Mirena
88150 Pap
Q0091 Pap Collection
99000 Specimen/Lab Handling
87210 Wet Mount
36415 Venipuncture
90384 Injection
J2790 Rhogam
Diagnostic Code 1
648.23 Anemia
795.01 Abnormal pap
611.72 Breast lump
V13.22 Cervical dysplasia, Hx
099.41 Chlamydia cult
V25.40 Contraceptive surveil unspec
625.3 Dysmenorrhea
V25.09 GYN counsl - contraceptive mgt
V26.33 Genetic counseling
V26.32 Genetic testing
054.10 Genital herpes
098.89 Gonorrhea cult
V72.31 GYN exam
455.6 Hemorrhoids
054.9 Herpes simplex
053.9 Herpes zoster
795.05 HPV
564.1 IBS
V06.8 Immunization, combination
V81.6 Infertility screening
996.65 IUD infect/inflammation
V25.12 IUD removal
V25.13 IUD removal and reinsertion
V25.42 IUD surveillance
611.0 Mastitis
626.2 Menstruation, excessive
626.6 Metrorrhagia
278.00 Obesity
V25.01 Oral contraception
278.02 Overweight
V72.32 Pap to conf normal after initial abnormal pap
V76.2 Pap smear, routine
V26.49 Procreative counseling
V74.5 STD screen
131.01 Trichomonal vulvovaginitis
V72.40 Unconfirmed pregnancy
599 UTI (or 646.63)
41.9 Vag infection
614.9 Vaginitis
616.1 Vaginitis and vulvovaginitis
V70.0 Well woman annual
V79.0 Screening for Depression
Diagnostic Code 2
648.23 Anemia
795.01 Abnormal pap
611.72 Breast lump
V13.22 Cervical dysplasia, Hx
099.41 Chlamydia cult
V25.40 Contraceptive surveil unspec
625.3 Dysmenorrhea
V25.09 GYN counsl - contraceptive mgt
V26.33 Genetic counseling
V26.32 Genetic testing
054.10 Genital herpes
098.89 Gonorrhea cult
V72.31 GYN exam
455.6 Hemorrhoids
054.9 Herpes simplex
053.9 Herpes zoster
795.05 HPV
564.1 IBS
V06.8 Immunization, combination
V81.6 Infertility screening
996.65 IUD infect/inflammation
V25.12 IUD removal
V25.13 IUD removal and reinsertion
V25.42 IUD surveillance
611.0 Mastitis
626.2 Menstruation, excessive
626.6 Metrorrhagia
278.00 Obesity
V25.01 Oral contraception
278.02 Overweight
V72.32 Pap to conf normal after initial abnormal pap
V76.2 Pap smear, routine
V26.49 Procreative counseling
V74.5 STD screen
131.01 Trichomonal vulvovaginitis
V72.40 Unconfirmed pregnancy
599 UTI (or 646.63)
41.9 Vag infection
614.9 Vaginitis
616.1 Vaginitis and vulvovaginitis
V70.0 Well woman annual
V79.0 Screening for Depression
Diagnostic Code 3
648.23 Anemia
795.01 Abnormal pap
611.72 Breast lump
V13.22 Cervical dysplasia, Hx
099.41 Chlamydia cult
V25.40 Contraceptive surveil unspec
625.3 Dysmenorrhea
V25.09 GYN counsl - contraceptive mgt
V26.33 Genetic counseling
V26.32 Genetic testing
054.10 Genital herpes
098.89 Gonorrhea cult
V72.31 GYN exam
455.6 Hemorrhoids
054.9 Herpes simplex
053.9 Herpes zoster
795.05 HPV
564.1 IBS
V06.8 Immunization, combination
V81.6 Infertility screening
996.65 IUD infect/inflammation
V25.12 IUD removal
V25.13 IUD removal and reinsertion
V25.42 IUD surveillance
611.0 Mastitis
626.2 Menstruation, excessive
626.6 Metrorrhagia
278.00 Obesity
V25.01 Oral contraception
278.02 Overweight
V72.32 Pap to conf normal after initial abnormal pap
V76.2 Pap smear, routine
V26.49 Procreative counseling
V74.5 STD screen
131.01 Trichomonal vulvovaginitis
V72.40 Unconfirmed pregnancy
599 UTI (or 646.63)
41.9 Vag infection
614.9 Vaginitis
616.1 Vaginitis and vulvovaginitis
V70.0 Well woman annual
V79.0 Screening for Depression
Diagnostic Code 4
648.23 Anemia
795.01 Abnormal pap
611.72 Breast lump
V13.22 Cervical dysplasia, Hx
099.41 Chlamydia cult
V25.40 Contraceptive surveil unspec
625.3 Dysmenorrhea
V25.09 GYN counsl - contraceptive mgt
V26.33 Genetic counseling
V26.32 Genetic testing
054.10 Genital herpes
098.89 Gonorrhea cult
V72.31 GYN exam
455.6 Hemorrhoids
054.9 Herpes simplex
053.9 Herpes zoster
795.05 HPV
564.1 IBS
V06.8 Immunization, combination
V81.6 Infertility screening
996.65 IUD infect/inflammation
V25.12 IUD removal
V25.13 IUD removal and reinsertion
V25.42 IUD surveillance
611.0 Mastitis
626.2 Menstruation, excessive
626.6 Metrorrhagia
278.00 Obesity
V25.01 Oral contraception
278.02 Overweight
V72.32 Pap to conf normal after initial abnormal pap
V76.2 Pap smear, routine
V26.49 Procreative counseling
V74.5 STD screen
131.01 Trichomonal vulvovaginitis
V72.40 Unconfirmed pregnancy
599 UTI (or 646.63)
41.9 Vag infection
614.9 Vaginitis
616.1 Vaginitis and vulvovaginitis
V70.0 Well woman annual
V79.0 Screening for Depression
Date
MM
DD
YYYY
Location
Office
Home
Hospital
Procedure
99385 New Preventative 18-39 (Annual)
99386 New Preventative 40-64 (Annual)
99395 Established Preventative 18-39 (Annual)
99396 Established Preventative 40-64 (Annual)
99401 Counseling - 15 Min.
99402 Counseling - 30 Min.
99403 Counseling - 45 Min.
99404 Counseling - 60 Min.
58300 IUD Insert
58301 IUD Remove
J7300 IUD 00 Copper
J7302 IUD 02 Mirena
88150 Pap
Q0091 Pap Collection
99000 Specimen/Lab Handling
87210 Wet Mount
36415 Venipuncture
90384 Injection
J2790 Rhogam
Diagnostic Code 1
648.23 Anemia
795.01 Abnormal pap
611.72 Breast lump
V13.22 Cervical dysplasia, Hx
099.41 Chlamydia cult
V25.40 Contraceptive surveil unspec
625.3 Dysmenorrhea
V25.09 GYN counsl - contraceptive mgt
V26.33 Genetic counseling
V26.32 Genetic testing
054.10 Genital herpes
098.89 Gonorrhea cult
V72.31 GYN exam
455.6 Hemorrhoids
054.9 Herpes simplex
053.9 Herpes zoster
795.05 HPV
564.1 IBS
V06.8 Immunization, combination
V81.6 Infertility screening
996.65 IUD infect/inflammation
V25.12 IUD removal
V25.13 IUD removal and reinsertion
V25.42 IUD surveillance
611.0 Mastitis
626.2 Menstruation, excessive
626.6 Metrorrhagia
278.00 Obesity
V25.01 Oral contraception
278.02 Overweight
V72.32 Pap to conf normal after initial abnormal pap
V76.2 Pap smear, routine
V26.49 Procreative counseling
V74.5 STD screen
131.01 Trichomonal vulvovaginitis
V72.40 Unconfirmed pregnancy
599 UTI (or 646.63)
41.9 Vag infection
614.9 Vaginitis
616.1 Vaginitis and vulvovaginitis
V70.0 Well woman annual
V79.0 Screening for Depression
Diagnostic Code 2
648.23 Anemia
795.01 Abnormal pap
611.72 Breast lump
V13.22 Cervical dysplasia, Hx
099.41 Chlamydia cult
V25.40 Contraceptive surveil unspec
625.3 Dysmenorrhea
V25.09 GYN counsl - contraceptive mgt
V26.33 Genetic counseling
V26.32 Genetic testing
054.10 Genital herpes
098.89 Gonorrhea cult
V72.31 GYN exam
455.6 Hemorrhoids
054.9 Herpes simplex
053.9 Herpes zoster
795.05 HPV
564.1 IBS
V06.8 Immunization, combination
V81.6 Infertility screening
996.65 IUD infect/inflammation
V25.12 IUD removal
V25.13 IUD removal and reinsertion
V25.42 IUD surveillance
611.0 Mastitis
626.2 Menstruation, excessive
626.6 Metrorrhagia
278.00 Obesity
V25.01 Oral contraception
278.02 Overweight
V72.32 Pap to conf normal after initial abnormal pap
V76.2 Pap smear, routine
V26.49 Procreative counseling
V74.5 STD screen
131.01 Trichomonal vulvovaginitis
V72.40 Unconfirmed pregnancy
599 UTI (or 646.63)
41.9 Vag infection
614.9 Vaginitis
616.1 Vaginitis and vulvovaginitis
V70.0 Well woman annual
V79.0 Screening for Depression
Diagnostic Code 3
648.23 Anemia
795.01 Abnormal pap
611.72 Breast lump
V13.22 Cervical dysplasia, Hx
099.41 Chlamydia cult
V25.40 Contraceptive surveil unspec
625.3 Dysmenorrhea
V25.09 GYN counsl - contraceptive mgt
V26.33 Genetic counseling
V26.32 Genetic testing
054.10 Genital herpes
098.89 Gonorrhea cult
V72.31 GYN exam
455.6 Hemorrhoids
054.9 Herpes simplex
053.9 Herpes zoster
795.05 HPV
564.1 IBS
V06.8 Immunization, combination
V81.6 Infertility screening
996.65 IUD infect/inflammation
V25.12 IUD removal
V25.13 IUD removal and reinsertion
V25.42 IUD surveillance
611.0 Mastitis
626.2 Menstruation, excessive
626.6 Metrorrhagia
278.00 Obesity
V25.01 Oral contraception
278.02 Overweight
V72.32 Pap to conf normal after initial abnormal pap
V76.2 Pap smear, routine
V26.49 Procreative counseling
V74.5 STD screen
131.01 Trichomonal vulvovaginitis
V72.40 Unconfirmed pregnancy
599 UTI (or 646.63)
41.9 Vag infection
614.9 Vaginitis
616.1 Vaginitis and vulvovaginitis
V70.0 Well woman annual
V79.0 Screening for Depression
Diagnostic Code 4
648.23 Anemia
795.01 Abnormal pap
611.72 Breast lump
V13.22 Cervical dysplasia, Hx
099.41 Chlamydia cult
V25.40 Contraceptive surveil unspec
625.3 Dysmenorrhea
V25.09 GYN counsl - contraceptive mgt
V26.33 Genetic counseling
V26.32 Genetic testing
054.10 Genital herpes
098.89 Gonorrhea cult
V72.31 GYN exam
455.6 Hemorrhoids
054.9 Herpes simplex
053.9 Herpes zoster
795.05 HPV
564.1 IBS
V06.8 Immunization, combination
V81.6 Infertility screening
996.65 IUD infect/inflammation
V25.12 IUD removal
V25.13 IUD removal and reinsertion
V25.42 IUD surveillance
611.0 Mastitis
626.2 Menstruation, excessive
626.6 Metrorrhagia
278.00 Obesity
V25.01 Oral contraception
278.02 Overweight
V72.32 Pap to conf normal after initial abnormal pap
V76.2 Pap smear, routine
V26.49 Procreative counseling
V74.5 STD screen
131.01 Trichomonal vulvovaginitis
V72.40 Unconfirmed pregnancy
599 UTI (or 646.63)
41.9 Vag infection
614.9 Vaginitis
616.1 Vaginitis and vulvovaginitis
V70.0 Well woman annual
V79.0 Screening for Depression
Date
MM
DD
YYYY
Location
Office
Home
Hospital
Procedure
99385 New Preventative 18-39 (Annual)
99386 New Preventative 40-64 (Annual)
99395 Established Preventative 18-39 (Annual)
99396 Established Preventative 40-64 (Annual)
99401 Counseling - 15 Min.
99402 Counseling - 30 Min.
99403 Counseling - 45 Min.
99404 Counseling - 60 Min.
58300 IUD Insert
58301 IUD Remove
J7300 IUD 00 Copper
J7302 IUD 02 Mirena
88150 Pap
Q0091 Pap Collection
99000 Specimen/Lab Handling
87210 Wet Mount
36415 Venipuncture
90384 Injection
J2790 Rhogam
Diagnostic Code 1
648.23 Anemia
795.01 Abnormal pap
611.72 Breast lump
V13.22 Cervical dysplasia, Hx
099.41 Chlamydia cult
V25.40 Contraceptive surveil unspec
625.3 Dysmenorrhea
V25.09 GYN counsl - contraceptive mgt
V26.33 Genetic counseling
V26.32 Genetic testing
054.10 Genital herpes
098.89 Gonorrhea cult
V72.31 GYN exam
455.6 Hemorrhoids
054.9 Herpes simplex
053.9 Herpes zoster
795.05 HPV
564.1 IBS
V06.8 Immunization, combination
V81.6 Infertility screening
996.65 IUD infect/inflammation
V25.12 IUD removal
V25.13 IUD removal and reinsertion
V25.42 IUD surveillance
611.0 Mastitis
626.2 Menstruation, excessive
626.6 Metrorrhagia
278.00 Obesity
V25.01 Oral contraception
278.02 Overweight
V72.32 Pap to conf normal after initial abnormal pap
V76.2 Pap smear, routine
V26.49 Procreative counseling
V74.5 STD screen
131.01 Trichomonal vulvovaginitis
V72.40 Unconfirmed pregnancy
599 UTI (or 646.63)
41.9 Vag infection
614.9 Vaginitis
616.1 Vaginitis and vulvovaginitis
V70.0 Well woman annual
V79.0 Screening for Depression
Diagnostic Code 2
648.23 Anemia
795.01 Abnormal pap
611.72 Breast lump
V13.22 Cervical dysplasia, Hx
099.41 Chlamydia cult
V25.40 Contraceptive surveil unspec
625.3 Dysmenorrhea
V25.09 GYN counsl - contraceptive mgt
V26.33 Genetic counseling
V26.32 Genetic testing
054.10 Genital herpes
098.89 Gonorrhea cult
V72.31 GYN exam
455.6 Hemorrhoids
054.9 Herpes simplex
053.9 Herpes zoster
795.05 HPV
564.1 IBS
V06.8 Immunization, combination
V81.6 Infertility screening
996.65 IUD infect/inflammation
V25.12 IUD removal
V25.13 IUD removal and reinsertion
V25.42 IUD surveillance
611.0 Mastitis
626.2 Menstruation, excessive
626.6 Metrorrhagia
278.00 Obesity
V25.01 Oral contraception
278.02 Overweight
V72.32 Pap to conf normal after initial abnormal pap
V76.2 Pap smear, routine
V26.49 Procreative counseling
V74.5 STD screen
131.01 Trichomonal vulvovaginitis
V72.40 Unconfirmed pregnancy
599 UTI (or 646.63)
41.9 Vag infection
614.9 Vaginitis
616.1 Vaginitis and vulvovaginitis
V70.0 Well woman annual
V79.0 Screening for Depression
Diagnostic Code 3
648.23 Anemia
795.01 Abnormal pap
611.72 Breast lump
V13.22 Cervical dysplasia, Hx
099.41 Chlamydia cult
V25.40 Contraceptive surveil unspec
625.3 Dysmenorrhea
V25.09 GYN counsl - contraceptive mgt
V26.33 Genetic counseling
V26.32 Genetic testing
054.10 Genital herpes
098.89 Gonorrhea cult
V72.31 GYN exam
455.6 Hemorrhoids
054.9 Herpes simplex
053.9 Herpes zoster
795.05 HPV
564.1 IBS
V06.8 Immunization, combination
V81.6 Infertility screening
996.65 IUD infect/inflammation
V25.12 IUD removal
V25.13 IUD removal and reinsertion
V25.42 IUD surveillance
611.0 Mastitis
626.2 Menstruation, excessive
626.6 Metrorrhagia
278.00 Obesity
V25.01 Oral contraception
278.02 Overweight
V72.32 Pap to conf normal after initial abnormal pap
V76.2 Pap smear, routine
V26.49 Procreative counseling
V74.5 STD screen
131.01 Trichomonal vulvovaginitis
V72.40 Unconfirmed pregnancy
599 UTI (or 646.63)
41.9 Vag infection
614.9 Vaginitis
616.1 Vaginitis and vulvovaginitis
V70.0 Well woman annual
V79.0 Screening for Depression
Diagnostic Code 4
648.23 Anemia
795.01 Abnormal pap
611.72 Breast lump
V13.22 Cervical dysplasia, Hx
099.41 Chlamydia cult
V25.40 Contraceptive surveil unspec
625.3 Dysmenorrhea
V25.09 GYN counsl - contraceptive mgt
V26.33 Genetic counseling
V26.32 Genetic testing
054.10 Genital herpes
098.89 Gonorrhea cult
V72.31 GYN exam
455.6 Hemorrhoids
054.9 Herpes simplex
053.9 Herpes zoster
795.05 HPV
564.1 IBS
V06.8 Immunization, combination
V81.6 Infertility screening
996.65 IUD infect/inflammation
V25.12 IUD removal
V25.13 IUD removal and reinsertion
V25.42 IUD surveillance
611.0 Mastitis
626.2 Menstruation, excessive
626.6 Metrorrhagia
278.00 Obesity
V25.01 Oral contraception
278.02 Overweight
V72.32 Pap to conf normal after initial abnormal pap
V76.2 Pap smear, routine
V26.49 Procreative counseling
V74.5 STD screen
131.01 Trichomonal vulvovaginitis
V72.40 Unconfirmed pregnancy
599 UTI (or 646.63)
41.9 Vag infection
614.9 Vaginitis
616.1 Vaginitis and vulvovaginitis
V70.0 Well woman annual
V79.0 Screening for Depression