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wfriddle

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I was wondering if anyone could advice on how to properly use the new diagnosis codes for a well woman exam. I see there are 2 codes, one for normal finding and one for abnormal findings. Do we have to wait until we get pap smears results back on all well women exams in order to bill them out? We normally bill out these type of visits by the next day. Can we use normal findings at the time of service if the provider does not find anything then?
 
Wwe

We use the V72.31 for the initial WWE if they have an abnormal result and return for another pap then we use the V72.32.

Melissa Brownlow, CPC
 
Icd-10

We also use V72.31 for our Well woman exams. In ICD-9 it does not state anything about the findings just "Routine gynecological examination". In ICD-10 however there are two codes Z01.411 "Encounter for gynecological examination (general) (routine) with abnormal findings" and Z01.419 "Encounter for gynecological examination (general) (routine) without abnormal findings". Do we use Z01.419 until there is something abnormal? Does the (general) mean we can use these codes even if it is not routine? For example if the patient does have an abnormal finding and comes back in for a re-pap could we use that "with abnormal findings" code then, even though that is no longer a routine exam?
 
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I-10-CM code for well woman

You must apply codes for the conditions or circumstances known at the time you are billing -- so, if you don't yet have the result, it is appropriate to code for a screening without abnormal results. If you can wait (and our lab turns these around in a day -- can you wait a day to bill?), then apply the code as per the result.
 
ICD-10 for well woman

I had a similar question. If a patient presents for her well-woman exam and a breast lump is found at the time of the exam, the provider orders a diagnostic mammogram, etc, I would assume that changes the code to V01.411, rather than V01.419 since there was an "abnormal finding" at the time of the visit. I wonder if anytime they discuss another problem at the time of the visit, i.e. menorrhagia, etc, is that still considered "abnormal finding" and should the appropriate code be V01.411? And how will payors view the V01.411 code?
 
The well woman with abnormal finding is Z01.411 and the discovery of a breast lump does qualify as an abnormal finding. However if the patient presents with symptoms or complaints the the exclude 1 note instructs you code only the signs and symptoms meaning the well woman would need to be rescheduled.
 
The Official Guidelines for Chapter 21 for routine and administrative exams state that, "Some of the codes for routine health examinations distinguish between "with" and "without" abnormal findings. Code assignment depends on the information that is known at the time the encounter is being coded. For example, if no abnormal findings were found during the examination, but the encounter is being coded before test results are back, it is acceptable to assign the code for "without abnormal findings."

So per these guidelines you would not need to wait for test results to come back to code appropriately for the encounter.
 
If a female patient is presenting for a routine general wellness visit at a family practice, and a pap is performed, and there are no abnormal findings; should we include Z00.00 with Z01.419? or Z01.419 will suffice?
:confused:
 
If you look in the coding guidelines at the end of the Z chapter guidelines is a listing if Z codes and categories that first listed only allowed. Z00 and Z01 are categories whose codes are first only allowed. So if you did a general wellness and a well woman together you would use the Z00.00 with the Z code for the screening PAP
 
well women visit

You would use Z01.419without abnormal findings if no new issues were found at the visit, even if the patient has a chronic problem. You would use Z01.411 with abnormal findings if a new problem is found. Do not wait for path report to code them.
 
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