Preventive Services without a Pelvic Exam

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 obstetrician–gynecologist. 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 obstetrician–gynecologist.

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 obstetrician–gynecologist, 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:
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.

Preventive Services without a Pelvic Exam

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