# Office Visits with Z01.419



## ELBrock (Oct 25, 2019)

Hello! I am a new OB coder, and was hoping to receive some clarification. Can the "Encounter for gyn exam (general) (routine) with/without abnormal findings" diagnosis codes be used for a regular office visit, or are those codes reserved for the Annual Exam? I had a situation where a new patient came in for a complaint, and the provider did a full exam/counseling as I would normally see on an annual visit. The provider used a 99204 code with the Z01.419 diagnosis. I queried the provider asking if it should be a preventive visit code instead, according to the documentation, and he responded that he uses the gyn exam dx whenever he does a pelvic exam. 
**For Context** the complaint was heavy menstrual bleeding, which led to the pelvic exam. In addition to pelvic exam, the provider documented other body areas/organ systems reviewed, and also counseled on contraceptive methods and diet/nutrition, etc.
So I'm wondering if: 1) can the annual preventative visit CPT code only be used if the provider designates the visit as an annual exam, and 2) can the gyn exam dx be used whenever there is a pelvic exam.
Thank you!


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## dmunoz781 (Oct 25, 2019)

Hello Elyse, 

I do not code OB but I am familiar with E/Ms so I hope others chime in to add additional support. I would not use a preventative visit CPT as this was truly not a preventative visit and the pt in fact made the appointment and was seen for a true compliant. Your situation from what I understood is different than if the patient would have arrived for a preventative visit and an abnormality is found which requires attention allowing for both an office e/m and preventative visit to be billed or if the pt came in for a preventative visit with an abnormality is found which is minor, doesnt require attention and only the preventative is captured; check out page 37 in 2020 CPT for the full text to distinguish the scenarios. 

Furthermore I would capture a 99204 if documentation and medical necessity support. Regarding the dx, I would like to ask what the final dx the provider documented was if any I know you said he used Z01.419 if the final dx was heavy menstrual bleeding I would capture that dx instead of Z01.419 as this was not truly routine.


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## ELBrock (Oct 26, 2019)

Thank you very much for your reply. When you think about the DX description as "routine," as it states in the code, then that kind of puts it in context. Since the provider did not document that this visit was for an annual exam and the heavy menstrual bleeding was an additional complaint, then the preventative CPT wouldn't be appropriate. Also, since the complaint is what led to the gym exam, I now realize that "routine" also isn't appropriate. So put that way, I guess the documentation should specify the visit is for an annual/wellness visit if one is to code it as such, and the Z01.411/419 DX would only be used if this is a regularly "routine" screening and not a diagnostic exam. 
Thanks again for the input!


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## mitchellde (Oct 27, 2019)

From the original post this was not a preventive visit so it would be incorrect to use the Z01.419 code.  To answer the question of whether you can use the Z01.419 with an OV, the answer is no.  It must be either the prevent CPT code or the G0101 and Q0091 codes depending on payer.  For a provider to perform a pelvic exam during a problem oriented visit as you have here is simply part of the diagnostic process, much like examining the throat for a sore throat encounter.  You do not get any additional points or codes for this. Use the dx code(s) for the symptoms or final diagnosis whichever is documented


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## Tazlar (Dec 23, 2019)

I have not had any questions or problems using the Z01.419/411 with an office visit E&M. Alaska state Medicaid does not pay for preventive exams unless the patient is under 21.  I use the codes along with the problem codes of there are any. BCBS pays on this as well.


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