# Well woman exam



## rleif1sun (Jul 30, 2018)

Patient comes to gynaecologist for well womens exam  but declines  vaginal, cervix and uterus examination (breast where examined). can i still code diagnosis *Z01.419*(Encounter for gynecological examination (general) (routine) without abnormal findings)? or do i use *Z00.00*(Encounter for general adult medical examination without abnormal findings)?


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## ahguzman (Aug 1, 2018)

What CPT are you using?  Many payers have requirements for billing wellness exams, especially preventive GYN exams.


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## rleif1sun (Aug 2, 2018)

99395


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## ahguzman (Aug 6, 2018)

https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html


Refer to the payor for that patient to verify the services performed support billing 99395.


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## mamatimbo (Jun 25, 2019)

Question, patient comes in for annual gyn exam but because of menstruation, she declines exam. What CPT and ICD-10 would be coded? Because no exam was completed, I am unable to use Z01.419, no problems noted.


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## ELBrock (Oct 24, 2019)

According to ACOG, An encounter for GYN exams are still billable even without a pelvic exam. The Z00.00 wouldn't be appropriate when performed by an OB-GYN, since payers typically allow 2 annuals, when one is done by an OB-GYN



			https://m.acog.org/About-ACOG/ACOG-Departments/Coding/Preventive-Services-without-a-Pelvic-Exam


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