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Well Woman minus pelvic exam

  1. Default Well Woman minus pelvic exam
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    How do others handle this situation. Patient comes in for Well Woman exam, however she is post hysterectomy. Can V72.31 still be used even though no Pelvic exam was done? Does anyone have any documentation on this I can present to my doctors? Thanks

  2. #2
    Greeley, Colorado
    No, I would use V70.0. Take the definitions out of ICD-9 as supporting documentation. V72.31 states
    General gynecological examination with or without Papanicolaou
    Pelvic examination (annual) (periodic)
    Lisa Bledsoe, CPC, CPMA

  3. Default Well Woman minus Pelvic Exam
    Thanks Lisa, but I tried that with my doctor. The response was that if he doesn't have to do a pap to be able to use V72.31, why is a pelvic exam required. Where does it state that? How would you combat that?

  4. #4
    Greeley, Colorado
    The actual definition of V72.31 is pelvic is right there in black and white in the ICD-9 manual. If he's not doing a pelvic he should not report this ICD-9. A gyn exam is a pelvic exam. Gynecology is defined in Taber's Medical Dictionary as "the study of the disease of the female reproductive organs and the breasts". If he isn't doing a pelvic how is he doing a gyn exam?
    V70.0 is a general health check up per ICD-9.

    Sounds like your doctor is a little stubborn..
    Last edited by Lisa Bledsoe; 08-17-2010 at 07:47 AM.
    Lisa Bledsoe, CPC, CPMA

  5. Default
    Lisa Curtis is absolutely right. What is gyn exam includes mainly pelvic examination. Pelvic examination can be undertaken in any form- digital or speculum examination or pelvic examination under anesthesia or even inderectly digital rectal examination. May be he meant to have only 'inspection'. he can have inspectional examination of the external genitalia but it cannot be reported with coding.
    Another point is there is good reason to have a pelvic examination for post hysterctomy (usually would have been given a schedule after 2weeks, 6weeks and even more after) - now, a speculum examination to know there is a vault prolapse or any -cele or infection, apart from her any complaint pertaining to the late effect. Once has come for examination, we should give her the pelvic exam by way of a speculum examination atleast, if not a per vaginal needed, for the above suspected or expected condition, no matter if it turns out to be negative.
    Yet another reason to have a pelvic examination is to confirm that there is an acquired absence of Cx and uterus and assgn a code
    V88.01 along with your V72.31
    Last edited by preserene; 08-16-2010 at 06:02 PM.

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