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Wiki Well woman exam

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rleif1sun

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Patient comes to gynaecologist for well womens exam but declines vaginal, cervix and uterus examination (breast where examined). can i still code diagnosis Z01.419(Encounter for gynecological examination (general) (routine) without abnormal findings)? or do i use Z00.00(Encounter for general adult medical examination without abnormal findings)?
 
Question, patient comes in for annual gyn exam but because of menstruation, she declines exam. What CPT and ICD-10 would be coded? Because no exam was completed, I am unable to use Z01.419, no problems noted.
 
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