Complete ICD-10-CM coding and documentation guide for icd-10 coding for well woman exam includes clinical validation requirements, medical necessity guidelines, and coding policies.
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Essential facts and insights about ICD-10 Coding for Well Woman Exam
Use ICD-10 code Z01.411 for encounter for gynecological examination (general) (routine) with abnormal findings, ensuring proper documentation in clinical notes.
Additional codes that may be used with this diagnosis
Encounter for screening mammogram for malignant neoplasm of breast
Use when a mammogram is performed during the exam.
The ICD-10 code for a well woman exam without abnormal findings is Z01.419, while Z01.411 is used if there are abnormal findings.
For a well woman exam with a Pap smear, use Z01.411 or Z01.419, and add Q0091 for the Pap smear procedure.