Wiki GYN Preventative Exam

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susanstew01

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Please help. I need clarification and expertise when it comes to ICD 10 coding for an annual gynecological exam. Can someone please help, when do I use "without abnormal findings" and "with abnormal findings?" Is it only if the provider finds a breast lump, yeast infection, etc or do I wait until I receive the results from the pap smear? Maybe I am thinking too hard but wonder if this would not be the same protocol as waiting for pathology when surgery is done. I would welcome any input and documentation you might have on the subject. Thank you so much. :confused:
 
You do not wait for the PAP results. Just use the without abnormal findings if nothing else is found. An abnormal finding is an issued documented as being discovered by the provider when the patient present asymptomatic.
 
I am sorry to be a pain but I need more clarification.........can you please expand.........a patient comes in for an annual exam, the provider codes it as "without abnormal finding" however she also codes 'postmenopausal atrophic vaginitis." Does that not constitute an abnormal finding?

Is it only abnormal when something new is found? Example: patient comes in for annual but has a history of menometrorrhagia and still complains of the same.

Thank you so much.
 
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