# GYN exam and when to use z01.411



## cwestman (Aug 21, 2018)

I'm looking for clarity when using encounter for GYN exam with abnormal findings not related to GYN portion of the visit
Pt presents to establish and her Physical 
Comprehensive Hx 10 system exam with 9 bullets for female exam 
her HPI and ROS detailed a concern with with a cyst with changes
 in addition Exam revealed thromegaly 
all issues were addressed in the assessment and plan
I'm wonder if z01.411 is appropriate  since the abnormal findings aren't GYN related
would it be more appropriate to use z01.01(27 yr old) for the abnormal physical findings and z01.419 since the Gyn portion of the exam was normal.
Honestly I thought that using both codes better defined the visit 
however billing rejected 
Is there a better way to describe the OV?
 Very much appreciate your time and advise
Cheri


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## KokilaVenkatesan (Sep 3, 2018)

*Gyn Exam With/without findings*

If a patient is came for gynecological exam with any symptoms related to Genitals can only be reported with Dx-Z01.411.
If not the symptoms is related to some other physicals then we need to add Dx-Z01.419.

Thanks,
Kokila Venkatesan-CPC-A


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## ahguzman (Sep 4, 2018)

I don't know of any guidance that states abnormal findings must be related to GYN to report Z01.411.   Also, neck and thyroid are routinely checked at a 
GYN preventive exam.  Thyromegaly is an abnormal finding.  I think Z01.411 is appropriate to report primary and secondary dx possibly would be cyst you mentioned or thyromegaly...can't be more specific without actual dictation.


AHG,
CPC, CPMA


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