Jamie Posted Tue 23rd of April, 2019 13:58:51 PM
A patient presents to a family practice physician for their annual GYN exam. The provider and patient decide to defer the pelvic exam and pap smear due to lack of risk factors and patient's age. They discuss the patient's current GYN health and risk factors and complete a breast exam. Would Z01.419 still apply to the visit? Is a pelvic exam required for this code to apply?
SuperCoder Answered Wed 24th of April, 2019 06:11:11 AM
Thank you for your question.
As per the provided documentation, ICD-10-CM code Z01.419 (Encounter for gynecological examination (general) (routine) without abnormal findings) is appropriate. Even if the physician did not perform the pap smear and pelvic exam, reporting the above-mentioned ICD-10 code is appropriate. Routine gynecological preventive services do not require that a pelvic exam be performed.
Hope that helps.
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