Wiki GYN annual exam, no pap, pelvic or breast exam

Hello,
We had a patient scheduled for annual Health Maintenance exam she did not want breast or pelvic exam. She was not due for a pap. She discussed irregular periods. Our doctor submitted E/M code rather than the HME code. Should I have asked them to bill the HME CPT instead? (The patient is now inquiring on this) I was under impression if no pelvic or breast exam and an issue discussed we should do E&M instead, but maybe we don't have to have all of those elements to bill the HME CPT? Thanks, Desiree

It sounds like (regardless of how it was scheduled), that the patient received a problem oriented visit, not a preventive visit. If that's the case, then 99202-99215 are likely the correct CPT code set.
I'm not sure what you're referring to as "HME CPT"? If you mean preventive 9938x-9939x, that is not what should be coded if the patient did not receive preventive care. If you mean Medicare's G0101, that is specific to a breast and pelvic exam which the patient had neither and would not be appropriate.

Thank you. Yes, I am referring to the preventive codes, 9938X-. So, in order to bill a GYN preventive visit, does the patient have to have at least a pelvic exam and/or breast exam? What if they come in for their annual and just talk about how they are doing, no issues, but no pap/pelvic or breast exam? Can we still use those preventive codes? Or would we switch that to E/M codes? Ty!

You can still bill a prevent code if all the other requirements are met. This may provide some guidance - https://www.acog.org/practice-management/coding/coding-library/preventive-services-without-a-pelvic-exam

Yes, as @Cmama12 pointed out 9938x-9939x can be billed without a pelvic and/or breast if there was still a preventive visit. My prior answer stated Medicare code G0101 requires pelvic/breast.
However, based on the very limited information given, it seems this was a problem oriented visit to discuss irregular periods as you did not mention any preventive care.