2025 ICD-10-CM code Z01.4
(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 gynecological examination.
Modifiers may be applicable depending on the circumstances of the visit and procedures performed.
Medical necessity for a gynecological examination is established by the patient's age and need for routine preventative care, symptoms suggesting a gynecological issue, or routine follow-up care after treatment or intervention. Each payer will have its own specific coverage guidelines.
The clinical responsibility lies with the physician performing the gynecological examination. This includes taking a patient history, performing a physical exam (potentially including a pelvic examination and/or Pap smear), and discussing findings and any necessary follow-up care with the patient.
- Factors influencing health status and contact with health services (Z00-Z99)
- Z01: Other special examinations and investigations of persons without complaint or reported diagnosis
In simple words: This code means a visit to the doctor for a routine gynecological checkup.This could include a pelvic exam and/or other related tests, but it's not for a specific problem or screening test.
This code signifies an encounter for a general gynecological examination, which may or may not include a cervical smear.It's used when a patient seeks a routine checkup or assessment of their reproductive health.This code excludes examinations specifically for pregnancy, contraceptive maintenance, or screening purposes (those have their own specific codes).
Example 1: A 25-year-old woman has an annual well-woman visit with her gynecologist, which includes a routine pelvic exam and discussion of contraception., A 40-year-old woman presents for a general gynecological examination following a period of irregular bleeding. The examination involves a pelvic exam but no specific diagnostic procedures., A 60-year-old woman presents for a routine follow-up gynecological examination after completing a course of hormone replacement therapy.
Complete patient history, including menstrual history, contraceptive use, sexual history, and any relevant past medical or surgical history.Documentation of the physical exam performed, including specific findings.Notes on any discussions or patient education provided. Any additional tests (e.g., Pap smear) performed should be documented separately.
** Always ensure proper documentation to support the medical necessity of the visit and any procedures performed.Z01.4 should not be used as the sole diagnosis if a specific gynecological issue is addressed.In those cases, code both the issue and the examination separately.
- Payment Status: Active
- Specialties:Obstetrics and Gynecology, Family Medicine
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center