2025 ICD-10-CM code Z01.41
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Factors influencing health status and contact with health services - Persons encountering health services for examinations (Z00-Z13) Factors influencing health status and contact with health services (Z00-Z99) Feed
Encounter for a routine gynecological examination.
Modifiers are not typically used with Z01.41. However, it's important to use the appropriate additional codes for abnormal findings, if any.
Medical necessity is established by the patient's age, the recommendation for routine screening and preventive care, and any reported symptoms or concerns. The frequency of routine gynecological exams varies by patient and should follow established guidelines.
The clinical responsibility lies with the physician conducting the gynecological examination, including taking a patient history, performing the physical exam, ordering and interpreting any associated tests (like Pap smears), and providing counseling or recommendations based on the findings.
- Factors influencing health status and contact with health services (Z00-Z99)
- Z01.41 is under the broader category of Z01 (Encounter for general examination), which falls under the chapter of Factors influencing health status and contact with health services (Z00-Z99).
In simple words: This code is used when a woman visits her doctor for a regular checkup of her reproductive organs. This visit may include a Pap smear.If anything unusual is found during the checkup, an additional code will be used to note it.
This code signifies an encounter for a routine gynecological examination, which may or may not include a cervical smear.Additional codes should be used to specify any abnormal findings discovered during the examination.This code excludes examinations performed post-hysterectomy for malignant conditions, screening cervical Pap smears not part of a routine gynecological exam, pregnancy examinations, and routine examinations for contraceptive maintenance.
Example 1: A 25-year-old asymptomatic woman presents for her annual well-woman visit, which includes a routine gynecological exam and Pap smear. No abnormalities are found., A 38-year-old woman reports irregular menstrual bleeding.Her routine gynecological exam reveals no obvious abnormalities, but a Pap smear is taken and reveals atypical squamous cells of undetermined significance (ASC-US).This would require additional coding beyond Z01.41 to reflect the ASC-US finding., A 42-year-old woman with a history of abnormal Pap smears in the past undergoes a routine gynecological examination, including a Pap smear, which this time shows no abnormalities. While the Z01.41 code would still be applicable, the physician may choose to use Z01.42 to code for a cervical smear after an initial abnormal result to confirm the absence of abnormalities
Documentation should include the date of the exam, a complete history (including menstrual history, sexual history, and family history), a detailed description of the examination findings, results of any lab tests (like Pap smear, HPV testing), and any counseling or patient education provided.
** While Z01.41 itself does not directly indicate the performance of a Pap smear, this is a common component of a routine gynecological examination. If a Pap smear is performed, appropriate additional coding may be necessary to reflect its results (e.g., normal, abnormal).Always consult the most up-to-date ICD-10-CM coding guidelines for accurate application.
- Payment Status: Active
- Modifier TC rule: Not applicable to this ICD-10 code.
- Specialties:Obstetrics and Gynecology, Family Medicine
- Place of Service:Office, Outpatient Clinic, Ambulatory Surgical Center