Confused seeking clarification...
currently I am coding pap for an FQHC where MD and OB providers both perform services. What confuses me is when provider only documents " this 54 year old female presents for pap" documents HPI= LMP, Last Mammo date, pregnancies, BCM, Family HX, all documented. " Pap done today, sureswab done today, if your pap is normal, will need to repeat again in 3 years, complete lab work, return to clinic for results"
*this I would code as Z12.4 with 99213 and Q0091 (or would E&M be coded alone?), but could it be Z01.419 with 9939- and Q0091?
**Also would it be appropriate to code Z01.419 with Z12.4 with 9939- and Q0091.
ICD-10 has Z01.419 as ENCOUNTER FOR GYN EXAMINATION GENERAL ROUTINE
Z12.4 ENCOUNTER FOR SCREENING FOR MALIGNANT NEOPLASM OF CERVIX
R87.619 NONSPECIFIC ABNORMAL FINDINGS.
I have found that when a patient has signs/symptoms pap would be diagnostic and are inclusive with E&M code
when pt has a routine pap and is asymptomatic is it considered a screening and either E&M and preventive cpt can be billed with Q0091.
is this the case?
Please advise. thank you in advance
currently I am coding pap for an FQHC where MD and OB providers both perform services. What confuses me is when provider only documents " this 54 year old female presents for pap" documents HPI= LMP, Last Mammo date, pregnancies, BCM, Family HX, all documented. " Pap done today, sureswab done today, if your pap is normal, will need to repeat again in 3 years, complete lab work, return to clinic for results"
*this I would code as Z12.4 with 99213 and Q0091 (or would E&M be coded alone?), but could it be Z01.419 with 9939- and Q0091?
**Also would it be appropriate to code Z01.419 with Z12.4 with 9939- and Q0091.
ICD-10 has Z01.419 as ENCOUNTER FOR GYN EXAMINATION GENERAL ROUTINE
Z12.4 ENCOUNTER FOR SCREENING FOR MALIGNANT NEOPLASM OF CERVIX
R87.619 NONSPECIFIC ABNORMAL FINDINGS.
I have found that when a patient has signs/symptoms pap would be diagnostic and are inclusive with E&M code
when pt has a routine pap and is asymptomatic is it considered a screening and either E&M and preventive cpt can be billed with Q0091.
is this the case?
Please advise. thank you in advance