# GYN exam w/abnormal findings



## asehr (Sep 9, 2015)

Does anyone know where I can find "specific" guidelines for an abnormal finding on GYN exam? Does it include patient complaints and/or physical findings on exam? Example, if we have a patient coming for annual exam, but complains of dyspareunia, physical exam is normal, is that considered an abnormal exam based on patient complaint? Or, a patient comes in for annual exam, physician notes "extremely dense breasts" on exam, is that an abnormal finding (my physicians say that is considered to be a variation of normal, depending on the patient)?
Any help would be appreciated!


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## jmarjane (Sep 9, 2015)

*Coding*



asehr said:


> Does anyone know where I can find "specific" guidelines for an abnormal finding on GYN exam? Does it include patient complaints and/or physical findings on exam? Example, if we have a patient coming for annual exam, but complains of dyspareunia, physical exam is normal, is that considered an abnormal exam based on patient complaint? Or, a patient comes in for annual exam, physician notes "extremely dense breasts" on exam, is that an abnormal finding (my physicians say that is considered to be a variation of normal, depending on the patient)?
> Any help would be appreciated!



See the linked article below....hope this answers your question:
http://news.aapc.com/the-a-b-c-ds-of-mammography-coding/


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## asehr (Sep 9, 2015)

Thanks for the article, but it only addresses mammograms. I need for GYN annual exams.


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## runninghonu@yahoo.com (Sep 15, 2015)

*abnormal vs normal*

I was wondering the same thing with the new "with abnormal findings" - only for routine adult exam.
If the patient presents for a routine exam, but they have a history of hyperthyroidism (controlled, but needing a refill while she's here) - does it become an abnormal exam?  

my thought is if the exam is normal (no issue's even though she has a disease) - to bill it as normal without abnormal findings.


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## aschull (Sep 21, 2015)

https://www.supercoder.com/my-ask-an...-versus-z00129

Someone posted this on another blog question and I found it quite helpful for deciding what to consider abnormal vs. normal on an exam.


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## mitchellde (Sep 21, 2015)

An abnormal finding is exactly what it states, an abnormal finding.  Something discovered by the provider in the course of examining a patient with no symptomatic concerns, All persisting issues are stated as stable? Refilling meds for a chronic problem is not abnormal.  A patient that presents for a preventive but then has a symptomatic issue is also not an abnormal finding.  A provider that feels a lump that U.S. unknown to the patient is an abnormal finding.  Or a patient with no complaints that has a high blood sugar reading that the provider discovers is an abnormal finding.


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## asehr (Sep 23, 2015)

Thank you!


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