2025 ICD-10-CM code Z01.419
(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 Chapter 21: Factors influencing health status and contact with health services Feed
Encounter for a routine gynecological examination without abnormal findings.
No modifiers are applicable to ICD-10 codes.
Medical necessity for this code is established by the patient's need for a routine gynecological examination as a part of preventative care or for follow-up care after a previous normal examination.The absence of specific complaints does not negate the medical necessity of preventative care.
The clinical responsibility for this code lies with the physician or healthcare professional performing the gynecological examination. This involves taking a patient history, conducting a physical exam, assessing the findings, and counseling the patient as appropriate.The physician must document the findings in the patient's record to justify the use of this code.
- Chapter 21: Factors influencing health status and contact with health services
- Z01.419 falls under the broader category of Z01.41 (Encounter for gynecological examination (general) (routine)) and the even broader category of Z01 (Encounter for other special examination without complaint, suspected or reported diagnosis).
In simple words: This code means a woman went to the doctor for a regular checkup and everything was fine. No problems were found.
This ICD-10-CM code, Z01.419, signifies an encounter for a general, routine gynecological examination in which no abnormal findings were identified.This code is used for documentation and billing purposes when a female patient undergoes a standard gynecological exam, and no disease, injury, or other condition requiring further medical attention is detected. The absence of abnormal findings is crucial for appropriate application of this code.It's important to note that this code is for the encounter itself, and a separate procedure code should be used if any procedures were performed during the visit.For instance, if a Pap smear was conducted, an additional procedural code would be necessary to accurately reflect that service.
Example 1: A 35-year-old female patient presents for her annual well-woman visit. The physician performs a routine gynecological exam, including a pelvic exam and breast exam. No abnormalities are detected.The encounter is coded as Z01.419., A 28-year-old female patient reports no specific complaints but wishes to have a general gynecological exam as a preventative measure.The examination reveals no abnormalities. The code Z01.419 is appropriate., A 42-year-old female patient presents for a follow-up gynecological examination following a previous normal Pap smear. The exam is unremarkable. Z01.419 is used to represent this encounter.
A complete medical record should include the patient's history, physical examination findings, and the physician's assessment. Specific documentation of the absence of abnormal findings is crucial to support the use of Z01.419.If any procedures were performed, those must be documented with appropriate procedure codes.
** This code should only be used when a routine gynecological examination is performed and no abnormal findings are present.If any abnormalities are identified, a different ICD-10-CM code should be used to reflect the specific findings.Always ensure proper documentation to support coding choices.
- Revenue Code: Revenue codes will vary depending on the payer and the specific services provided.Consult your payer's guidelines for appropriate revenue code assignment.
- RVU: RVUs are not directly associated with ICD-10 codes. RVUs are assigned to procedural codes (CPT, HCPCS) which are used in conjunction with ICD-10 codes for billing.
- Global Days: Not applicable.Global periods apply to procedural codes, not diagnostic codes.
- Payment Status: Active
- Modifier TC rule: Not applicable to ICD-10 codes.
- Fee Schedule: Not applicable. Fee schedules apply to procedure codes, not diagnosis codes.
- Specialties:Obstetrics and Gynecology, Family Medicine
- Place of Service:Office, Clinic, Hospital