Pelvic Exam

Madera, CA
Best answers
My auditor tells me I should have used code Z01.419. Patient didn't come in for a Gyne, I used Z12.4 for pap, which the Dr. did. Please tell me if I'm wrong.

Thank you!

GYN HPI 24yo G0 here for c/o pelvic pain 1 wk before her period and lasting to the first few days of her period.

Pt states she has "always" had this pain but it is increasing and she misses work because of it. She has taken tylenol and midol for the pain. She has not taken the naproxen she was previously prescribed because she has not had the pain since.

Pt states she has a history of colitis that was diagnosed in Mexico by lab tests. She states the pain from this and the pain before her period were separate but now she feels they are together. She occassionally gets constipation. Denies diarrhea.

Her periods are monthly, regular, lasting 7 or more days but only the first few days are painful.

Pt is sexually active and uses condoms for contraception. She has never had a pap smear