Mary Ann Shaieb
West Oakland OB/GYN
Farmington Hills, MI
Answer: Code 58999 is the only possibility in this case. Remember to send in documentation and a special report with the claim. The special report should include details of as many of the following components as possible: the complexity of diagnosis, final diagnosis, pertinent physical findings, diagnostic and therapeutic procedures, concurrent problems and follow-up care. (See CPT 1999, page 50 for a more thorough description of what to include.)