CPT® Code 99170

1. Indications

The anogenital examination, as described by CPT® Code 99170, is indicated in specific circumstances where there is a concern for trauma in the anogenital region of a child. The following conditions warrant this examination:

• Suspected Sexual Abuse - The primary indication for performing this examination is when there is a suspicion of sexual abuse, which may manifest through behavioral signs, disclosures from the child, or physical indicators.
• Trauma Assessment - The examination is also indicated for assessing any trauma that may have occurred in the anogenital area, which could be due to various forms of abuse or injury.

2. Procedure

The procedure for conducting an anogenital examination under CPT® Code 99170 involves several critical steps to ensure a thorough and accurate assessment of the anogenital region. The following procedural steps are outlined:

• Step 1: Preparation - The clinician prepares the examination area and ensures that all necessary equipment, including the colposcope and speculum, is ready for use. The child is positioned comfortably to facilitate the examination.
• Step 2: Colposcope Placement - The colposcope is positioned at the vaginal or anal opening. This positioning is crucial as it allows for optimal visualization of the anogenital tissues.
• Step 3: Speculum Insertion - A speculum is gently inserted into the vagina or anus. This instrument is used to separate the walls of the vaginal or anal canal, providing access for a comprehensive examination.
• Step 4: Tissue Inspection - The clinician inspects the vaginal or anal wall in its entirety. The speculum is rotated to examine the entire circumference, ensuring that no areas are overlooked.
• Step 5: Magnification Utilization - The examination is conducted using two or three different magnifications. This step is essential for identifying any subtle signs of trauma or injury that may not be visible to the naked eye.
• Step 6: Image Recording - If necessary, a videocolposcope may be employed to record images of the vaginal and anal tissues. This documentation is vital for medical records and may serve as evidence in cases of suspected abuse.

3. Post-Procedure

After the anogenital examination is completed, the clinician will typically provide post-procedure care instructions to the child and their guardians. This may include guidance on monitoring for any signs of discomfort or complications following the examination. Additionally, the clinician may discuss the findings of the examination, including any observed trauma, and outline the next steps for further evaluation or intervention if necessary. It is important to ensure that the child feels safe and supported throughout the process, and appropriate referrals to counseling or support services may be recommended based on the findings and the child's needs.