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Home/Diagnosis/ICD-10 Coding for Gynecology Exam

ICD-10 Coding for Gynecology Exam

Z01.419
Z01.411

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

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

Essential facts and insights about ICD-10 Coding for Gynecology 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

  • • Patient is asymptomatic with no abnormal findings.

Applicable To

  • • Routine gynecological exam without complaints

Important Notes

  • • Ensure documentation specifies 'routine' and 'without abnormalities'.

Encounter for gynecological examination with abnormal findings

Billable Code
Z01.411
Billable

Applicable To

  • • Gynecological exam with findings such as bleeding or masses

Important Notes

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

Additional codes that may be used with this diagnosis

Z12.72

Encounter for screening for malignant neoplasm of cervix

Use when a Pap smear is performed during the exam.

N95.0

Postmenopausal bleeding

Use when postmenopausal bleeding is identified during the exam.

Frequently Asked Questions

When should Z01.419 be used?

[Z01.419] is used for routine gynecological exams without any abnormal findings. Ensure documentation specifies 'routine' and 'without abnormalities'.

What is the difference between Z01.419 and Z01.411?

[Z01.419] is for routine exams without findings, while [Z01.411] is used when abnormalities are detected during the exam.

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