Preventive Services without a Pelvic Exam

Routine gynecological preventive services do NOT require that a pelvic exam be performed. Depending on the circumstances, either Z01.411, Encounter for gynecological examination (general) (routine) with abnormal findings, or Z01.419, Encounter for gynecological examination (general) (routine) without abnormal findings, may be used as the ICD-10-CM diagnosis code for the annual exam performed by an ob-gyn. Either code can be reported even if a pelvic exam is not done since some payers will reimburse for two annual exams in a given year if one of them is performed by an ob-gyn. That said, neither Z00.00, Encounter for general adult medical examination without abnormal findings, nor Z00.01, Encounter for general adult medical examination with abnormal findings, is appropriate when the visit is performed by an ob-gyn, particularly for those payers that will reimburse for two annual visits. This is payer-specific, so it is advised to check with your individual payers regarding this issue and be sure to get any instructions in writing.

As another example, preventive services for adolescents do not require a pelvic exam. Visits for adolescents and other patients who do not require or want a pelvic exam typically consist of the following components, but performance of any of the specific components is age and gender-specific:

  • Counseling/anticipatory guidance/risk factor reduction interventions
  • Age and gender appropriate comprehensive history
  • Age and gender appropriate comprehensive physical examination (if performed) including, in most cases, but not limited to:
      • gynecological exam
      • breast exam
      • collection of a Pap smear specimen
    • Discussions about the status of previously diagnosed stable conditions 
    • Ordering of appropriate laboratory/diagnostic procedures and immunizations
    • Discussions about issues related to the patient's age or lifestyle

    If you provided the other elements of the well-woman exam, you may report the preventive visit. For more information on well-woman exams, please read our article here.

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