Well Woman Healthcheck Program - Diagnosis And Treatment Form
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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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