# Well woman Z01.411 vs Z01.419



## eschrepel

When exactly are you supposed to use the Z01.411 with an annual well woman appt?  Only if you find something abnormal that day?  What if a patient comes in and everything today is normal, but we know that she has uterine fibroids that cause bleeding so we have her on birth control treating that.  In that case, would you use the Z01.411? Thanks, Erin


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## ciarahertzog

I came to the forum to post this question and you beat me to it.  

My coworker and I were thinking that maybe we should be waiting for pap results before billing the annual.  Of course, waiting for lab results significantly delays the billing process which we can't do.  And not every patient has a pap smear every year.  But the reason we were concerned about pap results was: what if you have a patient who is brought back in for a repeat pap smear and the insurance company questions your billing because her annual was billed with the Z01.419.

But you raise a great point with the other problems the patient may be experiencing. The book does say to "Use additional code to identify abnormal findings".  Maybe we should use the Z01.411 for the annual wellness portion of the visit and then list the codes for fibroids, or postmenopausal bleeding, or whatever else the patient may be experiencing.  Then we would only use the Z01.419 code if the patient was truly not having any other issues.  

Sorry for the long-winded response with no real answer to your question.  We are all in this together.


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## velindadossey

My understanding is that if fibroids are a known problem and the exam today is normal then you would use Z01.419.  But if you didn't know they had fibroids and you found them during that visit then you would use Z01.411 and the fibroids diagnosis.

I thought you only used Z01.411 if you had an abnormal finding during that current exam.


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## mitchellde

velindadossey said:


> My understanding is that if fibroids are a known problem and the exam today is normal then you would use Z01.419.  But if you didn't know they had fibroids and you found them during that visit then you would use Z01.411 and the fibroids diagnosis.
> 
> I thought you only used Z01.411 if you had an abnormal finding during that current exam.



Yes this is correct


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## KariJ30

I went to an ACOG convention this year in July.  We were told that abnormal findings are based on what you know at the exam.  So I don't think you would need to worry if the pap came back abnormal later.  Also, they said abnormal findings are what can be identified clinically at the exam, not just based on the patient's word.  They can also include breast problems such as a breast lump.  So the Z01.419 should work as long as the physician does not document any abnormal findings at that visit.  If you read the guidelines at the beginning of Chapter 21, it also clarifies coding before test or pap results come back.


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## CMPM12

I was wondering how it would be reported. If you have a well woman with an abnormal finding and it warrants and additional E/M how would you list the dx codes? 

Patient in for a well woman with vaginitis you would list Z01.411 then the vaginitis code correct, then list and E/M with mod 25 with only the vaginitis code meaning I list the vaginitis code on both the Well woman and E/M?


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## MKESSINGER

It is my understanding if the patient is found to have a problem that is discovered at the time of the yearly exam then you would use Z01.411 and use the dx code for the problem. You would not charge an additional E/M visit for the problem.

If anyone knows this is incorrect please let me know.

Thanks


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## MBass

*Z01.411 abnormal with problem visit*



MKESSINGER said:


> It is my understanding if the patient is found to have a problem that is discovered at the time of the yearly exam then you would use Z01.411 and use the dx code for the problem. You would not charge an additional E/M visit for the problem.
> 
> If anyone knows this is incorrect please let me know.
> 
> Thanks



It was to my understanding that we would still bill a problem visit E/M with modifier 25 because we are treating the patient for something outside of a normal annual exam. I have been adding the Z01.411 with problem dx and also an E/M with modifier 25 and the problem dx when we are treating it. When I see the patient has a problem but we are not treating or ordering anything, I do not bill an extra E/M then... 

What is everyone elses thoughts/ research show on this?


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## Jablanchfield

What about if a patient comes in for a WWE and then brings up her knee pain and the provider documents the concerns and orders a xray. The patient schedules a follow up to discuss the knee. Would this be an "abnormal finding"?


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