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Home/Diagnosis/ICD-10 Coding for Annual Gynecology Exam

ICD-10 Coding for Annual Gynecology Exam

Z01.419
Z01.411

Complete ICD-10-CM coding and documentation guide for icd-10 coding for annual gynecology exam includes clinical validation requirements, medical necessity guidelines, and coding policies.

Also Known as:
Annual Gyn Exam
Well-Woman Exam
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Key Information: ICD-10 Coding for Annual Gynecology Exam

Essential facts and insights about ICD-10 Coding for Annual Gynecology Exam

Use ICD-10 code Z01.419 for encounter for gynecological examination (general) without abnormal findings, ensuring proper documentation in clinical notes.

Primary ICD-10-CM Codes

Encounter for gynecological examination (general) without abnormal findings

Billable Code
Z01.419
Billable

Diagnostic Criteria

clinical:
  • No abnormalities detected during the exam

Applicable To

  • • Routine gynecological exam without abnormal findings

Important Notes

  • • Ensure documentation clearly states 'no abnormal findings' to support this code.

Encounter for gynecological examination (general) with abnormal findings

Billable Code
Z01.411
Billable

Applicable To

  • • Routine gynecological exam with abnormal findings

Important Notes

  • • Document all abnormal findings to support this code.
Ancillary Codes

Additional codes that may be used with this diagnosis

Z12.4

Encounter for screening for malignant neoplasm of cervix

Use when a Pap smear is performed during the exam.

N63.0

Unspecified lump in breast

Use if a breast lump is detected during the exam.

Frequently Asked Questions

What is the ICD-10 code for an annual gynecology exam?

The ICD-10 code for a routine annual gynecology exam without abnormal findings is Z01.419.

When should Z01.411 be used instead of Z01.419?

Use Z01.411 when there are abnormal findings during the gynecological exam, such as a breast lump or irregular bleeding.

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