Ob-Gyn Coding Alert

Here's what you should look for in your physician's documentation. When ICD-9 becomes ICD-10 in 2013, you will not always have a simple one-to-one relationship between old codes and the new ones. Often, you'll have more options that may require tweaking the way your physician documents a service and a coder reports it. Check out this common annual visit diagnosis, and discover what you'll report after October 1, 2013. When a patient comes in for an annual exam, you should attach V72.31 (Routine gynecological examination) to an annual visit code (99384-99386 for new patients, or 99394-99396 for established patients). ICD-10 difference: Instead of relying on one code, V72.31 will expand into two options. They are Z01.411 (Encounter for gynecological examination [general] [routine] with abnormal findings) and Z01.419 (... without abnormal findings). Physician documentation: The key difference between Z01.411 and Z01.419 is whether the visit revealed an abnormal finding during the [...]