Internal Medicine Coding Alert

Answer: V72.3 is the ICD-9 code for a GYN exam, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc., New Jersey. Medicare states that for a patient who has not had a pap test during the preceding three years and/or is considered to have a low-risk status, use ICD-9 codes V72.6 (laboratory examination) and V76.2 (special screening for malignant neoplasms, cervix).

Otherwise, if there is evidence on the basis of the patients medical history or other findings that she is at high risk of developing cervical cancer and her physician recommends she have a pap test performed more often than every three years, then use ICD-9 codes V72.6 and V15.89 (other specified personal history presenting hazards to health).

High-risk factors for cervical and vaginal cancer include early onset of sexual activity (under l6 years of age), multiple sex partners (five or more in a lifetime), history of sexually-transmitted disease (including HIV infection) and fewer than three negative pap smears within the previous seven years. A high-risk factor for vaginal cancer is DES (diethylstilbestrol)-exposed daughters of women who took DES during pregnancy).