Hello! I am a new OB coder, and was hoping to receive some clarification. Can the "Encounter for gyn exam (general) (routine) with/without abnormal findings" diagnosis codes be used for a regular office visit, or are those codes reserved for the Annual Exam? I had a situation where a new patient came in for a complaint, and the provider did a full exam/counseling as I would normally see on an annual visit. The provider used a 99204 code with the Z01.419 diagnosis. I queried the provider asking if it should be a preventive visit code instead, according to the documentation, and he responded that he uses the gyn exam dx whenever he does a pelvic exam.
**For Context** the complaint was heavy menstrual bleeding, which led to the pelvic exam. In addition to pelvic exam, the provider documented other body areas/organ systems reviewed, and also counseled on contraceptive methods and diet/nutrition, etc.
So I'm wondering if: 1) can the annual preventative visit CPT code only be used if the provider designates the visit as an annual exam, and 2) can the gyn exam dx be used whenever there is a pelvic exam.
Thank you!
**For Context** the complaint was heavy menstrual bleeding, which led to the pelvic exam. In addition to pelvic exam, the provider documented other body areas/organ systems reviewed, and also counseled on contraceptive methods and diet/nutrition, etc.
So I'm wondering if: 1) can the annual preventative visit CPT code only be used if the provider designates the visit as an annual exam, and 2) can the gyn exam dx be used whenever there is a pelvic exam.
Thank you!
diagnosis codes, diagnosis coding