Ob gyn policy and procedure manual 2026

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DEFINITIONS: Procedure Code 58661 - Laparoscopy, surgical; with the removal of adnexal structures (partial or total oophorectomy and/or salpingectomy). Procedure Code 58700 - Salpingectomy, complete or partial, unilateral or bilateral (separate procedure).
The 59400 CPT code description is used for vaginal delivery, which includes routine obstetric care like antepartum care, delivery, and postpartum care. For cesarean delivery, the 59510 CPT code description covers routine obstetric care, including antepartum care, the CPT code for cesarean section, and postpartum care.
Common CPT codes in gynecology include: 99201-99215: Evaluation and Management (E/M) codes for office visits. 57452: Colposcopy of the . 58100: Total abdominal hystomy. 58300: Insertion of intrauterine device (IUD).
Ask the four cardinal questions of every pregnant woman: 1) Do you feel fetal movement? (expect this only after ~20 wks) 2) Are you having vaginal bleeding? 3) Do you have any leaking fluid? 4) Are you having contractions?
58120 includes both the dilation and the biopsy, which is why it should be used instead of combining 58100 with a separate dilation code like 57800. These codes cannot be billed together due to a CCI edit.

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A complete policies and procedures manual will cover all possible topics related to company policy and the performance of duties. It will likely be a lengthy document and may be broken down into several different sections. The broadest topic is typically organizational policies.
The following are common GYN procedures and surgeries our physicians perform: Adhesiolysis. This is also called lysis of adhesions. Cervical (Cone) Biopsy. Colporrhaphy. Colposcopy. Dilation and Curettage (DC) Endometrial Ablation. Endometrial or Uterine Biopsy. Fluid-Contrast Ultrasound (FCUS)

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