What is the correct code for an office visit for a routine gynecological examination without any findings?

Coding a patient’s symptoms or conditions varies across specialties. For OB GYNs in particular, the ICD-10 codes they often find themselves relying on are rarely used in any other form of medicine. Due to their focus on women’s health, these codes are unlikely to crop up in an emergency room or a cardiologist’s office.

Here are 10 ICD-10 codes most commonly used by Ob-Gyn's

Commonly occurring ICD-10 codes are something you already know if you're established in your career, but if you're just getting started these codes are good to keep handy until you've got them memorized. 

Z01.419 – Encounter for gynecological examination (general) (routine) without abnormal findings

This code covers are routine visit from a patient to their OB/GYN. According to most industry experts, women between the ages of 21 and 29 should see their gynecologist at least once a year. Women ages 35 to 65 who have had negative Pap test results only need get a new test every 5 years, where as women 65 and older do not need such screenings at all.

Z12.31 – Encounter for screening mammogram for malignant neoplasm of breast

Given that 1 in 8 US women—about 12.4 percent—will develop invasive breast cancer in their lifetimes, it’s important to get screened regularly. Most OB/GYNs offer such screenings as a normal part of a routine check-up.

N80.9 – Endometriosis, unspecified

The stigma surrounding endometriosis has been something of a hot button issue lately, with many healthcare providers and ad campaigns centered around educating women about the diseases and encouraging them to speak up. Doctors are able to provide counseling and pain relief to individuals facing this diagnosis.

Z34.01 – Encounter for supervision of normal first pregnancy, first trimester

This code is exactly what it sounds like—a patient has come into their gynecologist to be examined during their first trimester of pregnancy.

099.011 – Anemia complicating pregnancy, first trimester

Especially for individuals suffering from anemia before they’re pregnant, the risk of anemia developing during a pregnancy is increased. There are three types of pregnancy-related anemia: iron-deficiency anemia, folate-deficiency anemia, and Vitamin B12 deficiency. A patient’s provider can administer blood tests to help determine which version she has, and can recommend treatment accordingly.

V25.5 – Encounter for contraceptive management, insertion of implantable subdermal contraceptive

Z30.018 – Encounter for initial prescription of other contraceptives

There are a wide variety of birth control methods available in today’s market. An IUD is referenced in this first code, and must be implanted by a medical professional. More traditional forms of birth control include pills and shots, which can be prescribed during a visit and then acquired according to a patient’s schedule.

N97.9 – Female infertility, unspecified

Roughly 10 percent of women ages 15 to 44 have difficulty getting pregnant or staying pregnant. There are numerous causes behind female fertility, and a OB/GYN can help identify—and potentially resolve—said issue.

Z11.3 – Encounter for screening for infections with a predominantly sexual mode of transmission

The CDC reported that rates of syphilis, gonorrhea and chlamydia have climbed to record highs, following 4 consecutive years of growth. OB/GYNs are equipped to screen, test, and treat STDs, but only if a patient takes the time to make an appointment to be checked out.

Ob-Gyn Practice Management and Electronic Health Records Software

These are just a handful of codes that an OB/GYN can rely on. Their role in women’s health is certainly an invaluable one. If your practice is looking for an alternative Ob Gyn EHR software we offer a full suite of features and integrations to bring your practice into a more efficient and productive state. Additionally, if you're interested in outsourcing medical transcription, we've got you covered there too. We have all the tools and services that allow us to take great care of your practice, so you can take care of your patients. 

Finding the correct code in your CPT book for administering a Pap smear isn’t easy. What comes up most often are codes 88141-88175, which are actually meant for pathologists examining a specimen. A search in your electronic health record will often find HCPCS code Q0091, “Screening Papanicolaou smear; obtaining, preparing, and conveyance of cervical or vaginal smear to laboratory.” Here’s when to use (and when not to use) that code.

The patient preventive medicine services codes 99381-99397 include an age- and gender-appropriate physical exam. According to CPT Assistant, performing a pelvic and breast exam, as well as obtaining a screening Pap smear, are all part of the comprehensive preventive service and should not be reported separately.1 Some private payers, however, will pay for obtaining a screening Pap smear using code Q0091 on the day of a preventive medicine service, so it is worth checking with them.

If a patient presents for a symptom or complaint that requires a Pap smear for diagnosis, the physical exam and obtaining the Pap smear are part of the E/M service and are not separately reportable. Additionally, you would not use Q0091 in this instance because that is a code for obtaining a screening Pap smear, not a diagnostic one.

For Medicare patients who still need a Pap smear, use Q0091 when a screening Pap smear is obtained even if this service is provided in addition to a wellness visit. For a screening clinical breast and pelvic exam, you can bill Medicare patients using code G0101, “Cervical or vaginal cancer screening; pelvic and clinical breast examination.” Note that this code has frequency limitations and specific diagnosis requirements.

Bottom line: Use Q0091 when obtaining a screening Pap smear for a Medicare patient. But also check with your private payers to see if they allow it in connection with a preventive medicine service.

1.    CPT Assistant. August 2005;15(8):13-15.

– Betsy Nicoletti, a Massachusetts-based coding and billing consultant

This document provides coding and billing guidelines for Gynecological & Rectal Exams.

Coding & Billing Guidelines

Blue Cross Blue Shield of North Dakota (BCBSND) has identified an increase in providers unbundling Preventive Evaluation and Management (E/M) and/or Gynecological Screening services. The claims reviewed include additional service which are inherent components of the codes such as pap smear collection or digital rectal examinations. The below billing guidelines are provided to educate providers on correct billing.

E/M Service & Gynecological Exam

When a physician performs a systemic physical examination as part of an annual gynecological examination and provides an unrelated, separately identifiable E/M on the same day both services may be billed. The appropriate medical E/M office visit code (99202-99215) may be reported with modifier 25 in addition to the gynecological examination (G0101). If the reported service(s) do not meet the component requirements of the codes billed the services should not be billed.

Preventive E/M & Gynecological Exam

When a physician performs an annual gynecological examination (G0101) and a preventive examination (9938X or 9939X) on the same day, there is significant overlap of the components of these two services (i.e., history, blood pressure, weight checks, and/or system gender and age-appropriate physical examination). However, the preventive examination may include services beyond the scope of the gynecological exam, such as counseling and anticipatory guidance, risk factor intervention, age-appropriate lab work, and certain screening tests (e.g., Pap Smear). Providers should only report the Preventive E/M when rendering a gynecological and systemic preventive annual E/M service.

Preventive E/M or Gynecological Exam & Pap Smear Collection

When a physician performs a Pap Smear (obtaining the specimen, preparing the slide, and conveyance - Q0091) on the same day as a gynecological examination (G0101) or preventive E/M (9938X or 9939X) providers should not report the Q0091 separately as the specimen collection is an inherent component of G0101, 9938X, and 9939X. 

If a physician performs a Pap Smear (obtaining the specimen, preparing the slide, and conveyance - Q0091) and an unrelated, separately identifiable E/M on the same day both services may be billed. The appropriate medical E/M office visit code (99202-99215) may be reported with modifier 25 in addition to Q0091. If the reported service(s) do not meet the component requirements of the codes billed the services should not be billed.

Preventive E/M & Digital Rectal Examination

Prostate cancer screening, digital rectal examinations (G0102) is considered an inherent component of both a problem focused E/M and Preventive E/M service. Separate reimbursement will not be made for G0102 when billed on the same date of service by the same performing provider billing an E/M.