2025 ICD-10-CM code Z01.42
Encounter for cervical smear to confirm findings of recent normal smear following initial abnormal smear.
Medical necessity for this code is established by the prior abnormal Pap smear result and the need for follow-up to ensure the absence of persistent disease or progression.
The clinician's responsibility includes performing a cervical smear (e.g., Pap test), evaluating the results, counseling the patient on the findings, and recommending appropriate follow-up care based on the confirmed normal result following an initial abnormal smear. This might include routine screening intervals or further diagnostic testing if indicated.
In simple words: This code is used when you see a doctor for a follow-up Pap smear after an earlier Pap smear had abnormal results, and the most recent results came back normal.
This code is used for an encounter with a healthcare professional for a cervical smear (e.g., Pap test) to confirm the findings of a recent normal smear following an initial abnormal smear result.It is used when the initial abnormal result necessitates a follow-up examination to ensure no further abnormalities are present.
Example 1: A patient had an abnormal Pap smear result three months ago.She has a repeat Pap smear today, and the results are normal.Z01.42 is used to code this encounter., A patient had an ASCUS Pap smear result six months ago, followed by a colposcopy showing CIN 1. She returns today for a follow-up Pap smear, which is normal. Z01.42 would be appropriate for this encounter., A patient with a history of an abnormal Pap smear last year returns for a scheduled follow-up Pap, which returns a normal result.Z01.42 is reported.
Documentation should include the reason for the encounter (follow-up after abnormal Pap), the date and result of the previous abnormal Pap smear, the date and result of the current Pap smear, and any recommendations for future surveillance.
** It is important to note that the guidelines for follow-up after an abnormal Pap smear may vary. Always follow current clinical guidelines and payer-specific requirements for appropriate follow-up and coding.
- Specialties:Family Medicine, Obstetrics and Gynecology, Women's Health, Internal Medicine
- Place of Service:Office, On Campus-Outpatient Hospital, Off Campus-Outpatient Hospital,Walk-in Retail Health Clinic