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Wiki Well Woman Exam

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dhamblett

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I am not clear on whether to use Z01.419 gyn w/o abnormal findings or Z01.411 gyn exam w/ abnormal findings in certain situations. For example if the doctor documents vaginal atrophy and prescribes a hormone replacement therapy then I would code Z01.411 and N95.2 postmenopausal atrophic vaginitis. Sometimes the doctor documents atrophy and patient either doesn't want to use hormone therapy or the doctor doesn't suggest it. How should I code appropriately?
 
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