Well Woman Exam/Annual HELP!!

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anne32

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So I am trying to understand what to code for Well Adult exams and Well Woman exams.

Well Adult(normal findings) and a pap: Z00.00, Z12.4 Is this correct?

If a patient has a Well Adult(normal findings) we would code: Z00.00, but what if they come back for a pelvic exam(normal) at a later date? Would we code Z01.411 or just the Z12.4? Can we bill another preventive e/m?
 
Well woman

Hello,
I'm trying to understand why a general medical exam Z00.00 or Z00.01 with PAP Z12.4 would be used for a female exam when Z01.411 or Z01.419 encounter for gynecological exam is available to choose from. The notes state it is "with or without cervical smear".
 
I am asking how to code when a woman presents for a general annual checkup along with a routine gyn exam on the same day.

I understand a well adult exam is Z00.00 and a routine gyn is Z01.419, but what if these are both done on the same day? How do we code?
 
Because the Z00 and the Z01.4 codes are first listed only allowed, you will not be able to code both on the same encounter because only one code can be used first. So we go back to the way we use to do this in the ICD-9 days before they made the V72.31 allowed first or secondary. This is we had this same situation,nowhere both were first listed only so we used the general adult code with code for the cervical screening. Now we find that we are back in this same scenario so code the Z00.00 with the Z code for the cervical screening.
 
Preventive/gynecological

I also have some questions on patient coming in for a well woman exam with a cervical pap smear without abnormal findings. We used V72.31 for a well woman exam with V76.2 for the cervical pap. V72.31(Routine Gynecological Exam) on the 99396 - the preventive exam for example. Then on the Q0091 (Screening pap smear, obtaining, preparing and conveyence of cervical or vaginal smear to laboratory) we used the V76.2 (Special screening for malignant neoplasm of the cervix). Some insurance companies pay for the conveyence of the pap in addition to the physical and some do not. It is without a doubt additional work compared to a physical without pap.
So in these cases where we would use V72.31 I believed we would now use
Z01.419 for Encounter for gynecological examination (general)(routine) without abnormal findings. And then Z12.4 (screening for malignant neoplasm of the cervix.

I have a question on the Z01.419 (Encounter for gynecological exam without abnormal findings) vs Z01.411(Encounter for gynecological exam with abnormal findings. - Senario - Patient comes in for gynecological exam and preventive exam is completed with cervical pap and during the exam patients blood pressure is elevated (pt already diagnosed with HTN and on medication) and the labs addressing patients last hemoglobin A1c is reviewed and patient is at risk for diabetes now and diet and life style changes were discussed in detail to address this problem. Patient also is on thyroid medication that she would like filled and thyroid labs would be run today to check to make sure patient is on correction medication dosage. As you see, most of these problems were discovered prior to this visit. At this time some of the problems must be addressed due to lack or control, or need for medication change or to set up a plan of care. A separte office visit will be added to this date of service addressing these problems.

1. On the Preventive /gynecological exam would you add the diagnosis
Z01.411 for Encounter for gynecological exam with abnormal findings?
2. If patient was scheduled for a Preventive/with or without gynecological exam and there was a need to add a problem focused visit on that date of service even though the problems were not discovered at this visit would you automatically code the visit with Z01.411 (Encounter for gynecological exam with abnormal finding (with gyne exam) or Z00.01 Encounter for general adult exam with abnormal findings and then add the diagnosis for the problem oriented visit in addition?
3. Or in order to use the encounter for general or gynecological exam with abnormal findings, do you have to find these abnormal findings during this particular visit to use the exam with abnormal findings?
 
The abnormal findings are findings by the provider at the time of service. This can be anything- a breast lump for example. You don't need the results from the pap to code it as abnormal. If a patient has a complaint, you would not code this as a preventive with an abnormal finding. A preventive visit is a no problem visit. In this case you would reschedule the preventive and bill this as an office visit or go ahead with the preventive and tell the patient to reschedule for the complaints. Of course this depends on the complaint and the serverity. I am under the impression you can no longer bill problem visits with preventive visits anymore.
 
I guess now I'm wondering, if a patient comes in for a routine gyn I know we would bill that out as a preventive, but lets say a few months later they come back for a general wellness exam. Would we bill another preventive E/M?
Are insurances paying for both?
 
She would not be able to come back for a general wellness exam. Any 99384-99397 codes can be billed only once a year. If a patient tries to have both done in the same year insurances will deny and bill the patient for full amount of second exam.
 
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Well woman and general well exam

If a woman comes in for a general pe you code the prevent visit with the icd 10 code for the general exam z00.00 ( assuming no abnormal findings) if she then comes in for a well woman exan in a week,a month or even the next day you code the prevent visit again ( not a medicare pt) and use icd10 code z01.419 ( if no abnormal findinds) . You can bill two prevent visits within the same year if one is a well woman. The dx code lets the insurance company know the visit reason. Now if you do both on the same date you can only bill one and use the dx for the general med exam because a general medical exam includes gender specific exam when performed at the same time. A woman can see her pcp for a general pe and her gyn for a well woman on the same date and both will pay. Hope that helps
 
Well woman and general well exam (williafm)

This was very helpful information as I am currently dealing with this situation now. I called Aetna and the representative was unable to define or advise what components are necessary to bill for a well woman exam. The patient we saw was a 36 year old woman who was scheduled for a pap only. We did the pap and pelvic exam, no breast exam. I am wondering if this is enough to bill a well woman exam. Any and all responses would be appreciated. I am not familiar with Ob/Gyn as I am in an internal medicine and family med.

Thanks
 
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