# Metaplasia of cervix



## hthompson (Aug 18, 2010)

So, in 8+ years, I've never had to code for this.  I guess there's always a first.  Pt came in for colpo results and MD diagnosed her with Metaplasia of cervix.  ICD-9 index says - omit code.  What's left to code?  Does that make this a non-billable visit due to that being the only diagnosis?  Anyone else dealing with this?  I can only set it aside for the day


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## ohn0disaster (Aug 19, 2010)

The ICD-9-CM official coding conventions actually uses "metaplasia of the cervix" as the example for _omit code_. Anyway, although you cannot code this dx, this doesn't make the visit non-billable. You can use a follow-up V code for the dx code, since the visit was a follow-up to the colpo, if that is the only dx addressed.


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## hthompson (Aug 19, 2010)

Would the follow up code V67.9 be appropriate alone?


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## preserene (Aug 19, 2010)

Colposcopy and Cervical Metaplasia Coding Dilemma:
Squamous metaplasia is a medical term used to describe the changes occurring to the cells in certain tissues of the body. Colposcopy is the first step in the evaluation of significant abnormalities on a Pap smear. It may be recommended by the cytologist after reviewing a Pap for which there are some significant clinical concerns. When you have a smear test of colposcopy the healthcare professional carrying out the test will be trained to look for certain changes to the cells of the cervix along with interpreting results provided by the laboratory. As squamous metaplasia is a naturally occurring process, the changes are not considered to be dangerous or increase the risk of cervical cancer, however, the chance of developing pre-cancerous or cancerous cells of the cervix continue to exist, even after a healthy smear or colposcopy so you must stay up-to-date with any screening procedures
Pap smear/other cyto smear would have come as Sq. metaplasia,unsatisfactory/atypical cells or or whatever, which gave the concern for the physician to make colposcopy and to find out whether it is going for dysplastic changes-( both by colpovisualization and cytology study like ASCUS- HGSIL- in other words to rule out CIN . 
Metaplasia means it is not reached yet to dysplasia.
So for you to code the procedural code may be for colposcopy-CPT Code 57421,57452-5746;1 and the diagnosis code:,so long as we do not have a specific code ( deleted for metaplasia),find out whether you can go with your cyto code- with your documented pap smear795xx. Use additional code if you have associated organism condition.
 And/or as OHN DISASTER said, provide a follow up V code.
Actually, we need an expert openion whether this meatplasia should be brought to the surface for coding at all, if no pap smear available.


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## ohn0disaster (Aug 20, 2010)

Oook, well, not exactly sure where preserene was going with that wealth of knowledge there. The first part of his/her comment was copied and pasted, or so it seems, but when he/she started to go into the actual coding it all became a huge "Huh??" to me...

This is for a follow-up to the colposcopy so it would be incorrect to code the cpt for the colpo on this DOS. Also, a colposcopy is not a pap smear so, unless it is documented on the note for the DOS in questions that the patient had abnormal findings on pap, this would be irrelevant. We can, of course, assume that there were abnormal findings on the patient's pap which is why they were refered for colpo but you cannot code an assumption.

V67.9 is the code for an unspecified follow-up, and I'm not sure as to the exact documentation you have for this visit, but I'm thinking that it wasn't unspecified since you know that the patient was there for the results of their colposcopy. I would code V67.59, other follow-up, as my primary code, and then maybe a code for abnormal finding. Again, I'm unsure of the actual documentation but maybe the code for abnormal finding; cytology specified site NEC, 796.9, would be appropriate. There could very well be a more specific code for your circumstance but you'd have to check against your documentation in the Tabular List of your ICD-9-CM book.

I hope this helps. Anyone else have any suggestions?


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## preserene (Aug 20, 2010)

"Oook, well, not exactly sure where preserene was going with that wealth of knowledge there. The first part of his/her comment was copied and pasted, or so it seems, but when he/she started to go into the actual coding it all became a huge "Huh??" to me..." ohnodisaster's qoute

Metaplasia  is first of all a confirmed histopathological finding, for one to document with. If not documented, we do not attempt to code it.
The bottom line is : Both our requests  are ‘requirements of documents' only. Without documentation it never happened .That is our NO 1 coding rule. I am aware of it also.
But as per our clinical knowledge and analysis we all know that the colposcopy and the statement/ document by  the physician Cx metaplasia  does not come out without combined  finding of colposcopy and the cytology studies. (There is a dictum like critical thinking and clinical analysis)
 However  you have come to the “other on specific abnormal findings; others. I am aware of it too.  Your coding of 796.9  is also "other non specific abnormal findings; other". But that cervical metaplasia could be labelled "NONSPECIFIC", I doubt.  
What I was trying to say  was:  in the event  of no code for metaplasia (ofcourse could be with good reason it was deleted) and there is no specific follow up code for colposcopy  cx, (we take it indirectly with the pap smear) if she /he could get some more documents which were the sources of the procedure and follow up, I only suggested for a little more analysis of the previous results/ or reason for this follow up to fix the code with more specificity.( and all the more she has come for the result);to find follow up codes to be closer to the descriptive terms metaplsia cx, colposcopy and abnormal findings with pap smear report if available. 
The reason why I gave a brief note is to say that the colposcopy is not done for any one just coming for the office visit  just with some complaints and by the pelvic examination alone. There would be definitely an associated cytological findings or atleast a simultaneous cyto study during that visit of colposcopy when the doctor visualizes those finding s which go for metaplasia.
I never came out with pin point code ; I just wanted senior coders to come with their suggestion for a better understanding of this dielemma in metaplasia coding. When I did not giv eacod enymber means I did not code it .I just came for openions  and suggestions.
Colposcopy codes are not for discussion now ( it was about the time of colposcopy procedure I am awareof that too). The code discussion is about the metapalsia result or report.
By the way, I do have some basic knowledge of these stuff and whether I copied or pasted from/ or printed it from my knowledge is immaterial at this juncture; like to read, read ; otherwise leave it. I think I have not brought forth anything like ‘nonsense' or not relating to the subject.  If so, I am sorry .
But anyway, your comments are, to some extent, condescending.  I am magnanimous and set it aside. 
 I know the forum is for me to learn and correct  as a stepping stone for success!
I say bye for a while!! Cool!!!


Metaplasia  is first of all a confirmed histopathological finding,  one to document with. If not documented, we do not attempt to code it.
The bottom line is : Both our requests  are ‘requirements of documents' only. Without documentation it never happened .That is our NO 1 coding rule. I am aware of it also.
But as per our clinical knowledge and analysis we all know that the colposcopy and the statement/ document by  the physician Cx metaplasia  does not come out without combined  finding of colposcopy and the cytology studies. (There is a dictum like critical thinking and clinical analysis)
 However  you have come to the “other on specific abnormal findings; others. I am aware of it too.  Your coding of 796.9  is also in connection with PAP SMEAR. What I was trying to say  was:  in the event  of no code for metaplasia (ofcourse could be with good reason it was deleted) and there is no specific follow up code for colposcopy  cx, (we take it indirectly with the pap smear) if she /he could get some more documents which were the sources of the procedure and follow up, I only suggested for a little more analysis of the previous results/ or reason for this follow up to fix the code with more specificity.( and all the more she has come for the result);to find follow up codes to be closer to the descriptive terms metaplsia cx, colposcopy and abnormal findings with pap smear report if available. 
The reason why I gave a brief note is to say that the colposcopy is not done for any one just coming for the office visit  just with some complaints and by the pelvic examination alone. There would be definitely an associated cytological findings or atleast a simultaneous cyto study during that visit of colposcopy when the doctor visualizes those finding s which go for metaplasia.
I never came out with pin point code ; I just wanted senior coders to come with their suggestion for a better understanding of this dielemma in metaplasia coding. When I did not giv eacod enymber means I did not code it .I just came for openions  and suggestions.
Colposcopy codes are not for discussion now ( it was about the time of colposcopy procedure I am awareof that too). The code discussion is about the metapalsia result or report.
By the way, I do have some basic knowledge of these stuff and whether I copied or pasted from/ or printed it from my knowledge is immaterial at this juncture; like to read, read ; otherwise leave it. I think I have not brought forth anything like ‘nonsense' or not relating to the subject.  If so, I am sorry .
But anyway, your comments are, to some extent, condescending.  I am magnanimous and set it aside. 
 I know the forum is for me to learn and correct  as a stepping stone for success!
I say bye for a while!! Cool!!!


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## ohn0disaster (Aug 20, 2010)

I really think that you are taking this much too personally, preserene. Nothing I said was condescending. I was merely stating that I'm not exactly sure what you were trying to explain. You are making the question asked much more complicated than it really is. My belief was that people use this forum to have things simplified for them. I did not claim that there was anything wrong with copying and pasting information. Put simply, I understood everything you copied and pasted, but when it came to your personal explanation I found it to be extremely confusing. To be honest, this newest post does not really help the matter. I never claimed that your post was nonsense. That was all your doing. I'm pretty sure that EVERY input is appreciated on these forums. I suggest that you take the posts for what they are, people helping others, rather than a personal attack on your basic knowledge of coding.

I stand by my last posted opinion on how to code this encounter and I'm sorry that it seemed to turn into some sort of drama.


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