How To Use CPT Code 99170

CPT 99170 describes the examination of a child’s genitals and anal area with magnification, typically using a colposcope, for suspected trauma, including image recording if performed. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 99170?

CPT 99170 can be used to describe the examination of a child’s genitals and anal area with magnification, specifically for cases where there is suspicion of trauma, such as sexual abuse or assault. This code is used when a physician or nonphysician practitioner uses a colposcope or digital camera with macro lenses to closely analyze and potentially record images of the external genitalia.

2. Official Description

The official description of CPT code 99170 is: ‘Anogenital examination, magnified, in childhood for suspected trauma, including image recording when performed.’

3. Procedure

1. A physician or nonphysician practitioner examines the child’s genitalia and anal areas under magnification, using a colposcope or digital camera with macro lenses.
2. If a colposcope is used, the provider analyzes the vulva, vagina, or other female genital organs with the help of light and magnification. Alternatively, a digital camera with macro lenses can be used to create images of the external genitalia.
3. If necessary, the provider may record images of the examination for documentation purposes.

4. Qualifying circumstances

CPT 99170 is used when there is suspicion of trauma, such as sexual abuse or assault, in a child. The examination focuses on the child’s genitals and anal area, and magnification tools like a colposcope or digital camera with macro lenses are used to aid in the analysis. This code is specific to cases involving childhood trauma and should not be used for routine examinations or other purposes.

5. When to use CPT code 99170

CPT code 99170 should be used when a physician or nonphysician practitioner performs a magnified examination of a child’s genitals and anal area for suspected trauma, such as sexual abuse or assault. It is important to ensure that the examination is necessary and relevant to the specific circumstances of the case before using this code.

6. Documentation requirements

To support a claim for CPT 99170, the provider must document the following information:

• Reason for the examination, including suspicion of trauma
• Details of the magnification tools used, such as a colposcope or digital camera with macro lenses
• Date and time of the examination
• Findings and observations from the examination
• Any images recorded during the examination, if applicable
• Signature of the physician or nonphysician practitioner performing the examination

7. Billing guidelines

When billing for CPT 99170, ensure that the examination is performed by a qualified physician or nonphysician practitioner and meets the criteria for suspected trauma. It is important to accurately document the examination and any image recording performed. Additionally, be aware of any specific guidelines or modifiers that may apply when reporting this code, such as modifier 25 for significant, separately identifiable evaluation and management services on the same day.

8. Historical information

CPT 99170 was added to the Current Procedural Terminology system on January 1, 2000. The code was later changed on January 1, 2014, to include the specific mention of colposcopic magnification in childhood for suspected trauma.

9. Examples

1. A physician using a colposcope to examine a child’s genitals and anal area for suspected sexual abuse, recording images of the examination.
2. A nonphysician practitioner using a digital camera with macro lenses to closely analyze a child’s external genitalia for signs of trauma, without recording images.
3. A physician performing a magnified examination of a child’s genitals and anal area using a colposcope, documenting findings and recording images for forensic analysis.
4. A nonphysician practitioner using a colposcope to examine a child’s genitals and anal area, without recording images, to assess potential trauma.
5. A physician using a digital camera with macro lenses to create images of a child’s external genitalia during a magnified examination for suspected trauma.
6. A nonphysician practitioner performing a colposcopic examination of a child’s genitals and anal area, documenting findings and recording images for further analysis.
7. A physician using a colposcope to closely analyze a child’s external genitalia for signs of trauma, without recording images, during an examination for suspected abuse.
8. A nonphysician practitioner using a digital camera with macro lenses to record images of a child’s genitals and anal area during a magnified examination for suspected trauma.
9. A physician performing a colposcopic examination of a child’s genitals and anal area, documenting findings and recording images for interpretation and reporting.
10. A nonphysician practitioner using a colposcope to examine a child’s genitals and anal area for suspected trauma, without recording images, and providing a detailed report of the findings.