Question Women's wellness exam

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so the clinic i work for has started the women's wellness exam , this is new to me can anyone help me code this i know code rang from 99381-99397 also do we bill Q0091 and p3001 to insurance or lab bill those codes. i have attach the provider note

Report Notes
Chief Complaint: Well Women's Exam

History of Present Illness: No present illness

Review of Systems
Cardiovascular:

Denies Chest Pain and Edema
Gastrointestinal:
Denies Abdominal Mass and Abdominal Pain
General:
Admits Able to Conduct Usual Activities and Comfortable
Denies Fatigue
Neurological:
Denies Dizziness
Psychiatric:
Denies Anxiety
Respiratory:
Denies Chronic Cough , Fever , Non-productive Cough and Productive Cough

Vital Signs
Temp 98.30 F - Oral, Pulse 90 b/m - Regular - Sitting, Respiration 16 b/m - Normal, BP 120/78 mm/Hg - Sitting - Left Arm - Standard Cuff Size SAO2 98% - Resting - Room Air, - Manual Recording
Comments: LMP--10/11/2020
Taken on Oct 15, 2020 at 3:22 PM by Mr Holte, Paula

Allergies
NKDA

Current Medications
Patient currently takes no medications

Physical Exam
menstruation present
ingrown pubic hair to left inguinal
pap smear exam (os closed, no vaginal discharged, IUD strings present)

Constitutional
Appearance: No distress, Alert and oriented x 3
Head and Face
Head: Inspection: No sig rashes
Eyes
Conjunctivae: Normal; Pupils and Irises: Normal; Eyelids/Ocular Adnexae: Normal
Ears Nose Mouth and Throat
Ears: External Ears: Normal; Otoscopic Examination: Normal; Hearing: Normal
Throat: Oropharynx: Normal; Findings: Normal
Neck
Inspection/Palpation: No sig adenopathy; Range of Motion: Supple
Respiratory
Respiratory Effort: Normal; Auscultation of Lungs: Normal
Cardiovascular
Findings: Regular rate and rhythm, S1/S2 present
Abdomen
Findings: Soft-nontender-nondistended, Normal bowel sounds present
Female Genitourinary
Findings: External genitalia normal, Vaginal mucosa well-estrogenized - good vaginal tone, Cervix without abnormality, No cervical motion tenderness, IUD strings visualized, Bimanual exam reveals no adnexal fullness - masses nor tenderness
Breast
Findings: Skin/nipples without observable abnormality, Breasts without palpable masses
Musculoskeletal
Findings: Normal
Skin and Subcutaneous Tissue
General Inspection: No gross abnormality noted on exposed skin surfaces
Neurologic
Cranial Nerves: Facial Nerve: No asymetry for facial droop
Gait and Station: Ambulatory
Psychiatric
Judgment and Insight: Appears appropriate; Mood and Affect: Affect appropriate


Assessment And Plan: Breast examination; Pap smear (IUD strings noted, OS closed, no vaginal discharge present); Well woman's examination completed.


Lab Order
10/15/2020
HPV COMBO ASSAY CA SCREEN(CPT-G0476) [Genital cervix]

Procedures
SCREENING PAP SMEAR BY PHYS (CPT-P3001), Units: 1.
OBTAINING SCREEN PAP SMEAR (CPT-Q0091), Units: 1.

Diagnoses
Encounter for gynecological examination (general) (routine) without abnormal findings - Z
 

csperoni

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P3001 "Screening Papanicolaou smear, cervical or vaginal, up to three smears, requiring interpretation by physician"
Q0091 "Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory"

P3001 is a HCPCs code for a laboratory/pathologist to use when interpreting the specimen. While I suppose it is possible you have an onsite laboratory, I doubt that is the situation.
Q0091 is appropriate as your practice is obtaining, preparing, and sending the PAP to an outside lab.

My suggestion is for the screening PAP to be listed in your EMR under the lab order, not procedure. I think that may be why you are getting confused.

Hope that helps!
 
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