# Well Woman minus pelvic exam



## jobrien66 (Aug 16, 2010)

How do others handle this situation.  Patient comes in for Well Woman exam, however she is post hysterectomy.  Can V72.31 still be used even though no Pelvic exam was done?  Does anyone have any documentation on this I can present to my doctors?  Thanks


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## Lisa Bledsoe (Aug 16, 2010)

No, I would use V70.0.  Take the definitions out of ICD-9 as supporting documentation.  V72.31 states 
General gynecological examination with or without Papanicolaou 
*Pelvic examination* (annual) (periodic)


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## jobrien66 (Aug 16, 2010)

*Well Woman minus Pelvic Exam*

Thanks Lisa, but I tried that with my doctor.  The response was that if he doesn't have to do a pap to be able to use V72.31, why is a pelvic exam required.  Where does it state that?  How would you combat that?


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## Lisa Bledsoe (Aug 16, 2010)

The actual definition of V72.31 is *pelvic exam*...it is right there in black and white in the ICD-9 manual.  If he's not doing a pelvic he should not report this ICD-9.  A gyn exam is a pelvic exam.  Gynecology is defined in Taber's Medical Dictionary as "the study of the disease of the female reproductive organs and the breasts".  If he isn't doing a pelvic how is he doing a gyn exam?
V70.0 is a general health check up per ICD-9.

Sounds like your doctor is a little stubborn..


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## preserene (Aug 16, 2010)

Lisa Curtis is absolutely right. What is gyn exam includes mainly pelvic examination. Pelvic examination can be undertaken in any form- digital or speculum examination or pelvic examination under anesthesia or even inderectly  digital rectal examination. May be he meant to have only 'inspection'. he can have inspectional examination of the external genitalia but it cannot be reported with coding.
Another point is there is good reason to have a pelvic examination for post hysterctomy (usually would have been given a schedule after 2weeks, 6weeks and even more after) -  now, a speculum examination to know there is a vault prolapse or any -cele or infection, apart from her any complaint pertaining to the late effect. Once has come for examination, we should give her the pelvic exam by way of a speculum examination atleast, if not a per vaginal needed, for the above suspected or expected condition, no matter if it turns out to be negative.
Yet another reason to have a pelvic examination is to confirm that there is an acquired absence of Cx and uterus and assgn a code 
V88.01 along  with your V72.31


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