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Home/Diagnosis/ICD-10 Coding for Gynecological Exam

ICD-10 Coding for Gynecological Exam

Z01.419
Z01.411

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

Also Known as:
Pelvic Exam
Well-Woman Exam
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Key Information: ICD-10 Coding for Gynecological Exam

Essential facts and insights about ICD-10 Coding for Gynecological Exam

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

Primary ICD-10-CM Codes

Encounter for gynecological examination (general) (routine) without abnormal findings

Billable Code
Z01.419
Billable

Diagnostic Criteria

clinical:
  • • No symptoms or abnormal findings present

Applicable To

  • • Routine gynecological exam without findings

Important Notes

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

Encounter for gynecological examination (general) (routine) with abnormal findings

Billable Code
Z01.411
Billable

Applicable To

  • • Routine gynecological exam with findings

Important Notes

  • • Ensure all abnormal findings are documented with appropriate follow-up.
Ancillary Codes

Additional codes that may be used with this diagnosis

N93.9

Abnormal uterine and vaginal bleeding, unspecified

Use when specific abnormal bleeding is noted during the exam.

Frequently Asked Questions

What is the ICD-10 code for a routine gynecological exam?

The ICD-10 code for a routine gynecological exam without abnormal findings is Z01.419. If there are abnormal findings, use Z01.411.

When should Z01.411 be used?

Use Z01.411 when a routine gynecological exam reveals abnormal findings, such as lesions or abnormal bleeding.

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