What is the ICD-10-CM code for a patient who undergoes a routine gynecological examination in her ob/gyn physicians office during which findings were normal?

October 12, 2017

By Tiris Mjelde

The practice of medicine has changed dramatically in the last 25 years or so. New conditions have been discovered and many new treatments and medical devices have been developed. The ICD-10 code set that became effective on October 1, 2015, tries to capture the current practice of medicine and provide flexibility as it changes in the future.

Provided below are some of the common issues that you may encounter when coding Pap tests with the new ICD-10 coding set.

1) Diagnostic vs. Screening Pap test:

Determining whether the patient is being seen for a diagnostic or screening Pap test will help you determine the appropriate ICD-10 code to submit to the laboratory. A diagnostic code should be used when there are signs or symptoms of disease. To help you determine if a Pap test was performed for diagnostic purposes, here are a few things to consider.

A Pap test is considered diagnostic if it meets any of the following criteria:

A) The patient has been treated for or is being treated for cancer of the cervix, uterus or vagina:

• Endocervical cancer (C53.0)
• Endometrial cancer (C54.1)
• Exocervical cancer (C53.1)
• Myometrial cancer (C54.2)
• Cervical cancer, unspecified (C53.9)
• Uterine fundal cancer (C54.3)
• History of cervical cancer (Z85.41)
• Uterine cancer, unspecified (C55)
• Vaginal cancer (C52)
• History of uterine cancer (Z85.42)
• History of vaginal cancer (Z85.44)

B) The patient is being seen for follow up on a previous abnormal Pap test

• Cervical Pap with ASCUS (R87.610)
• Vaginal Pap with ASCUS (R87.620)
• Cervical Pap with ASC-H (R87.611)
• Vaginal Pap with ASC-H (R87.621)
• Cervical Pap with LGSIL (R87.612)
• Vaginal Pap with LGSIL (R87.622)
• Cervical Pap with HGSIL (R87.613)
• Vaginal Pap with HGSIL (R87.623)
• Cervical high-risk HPV positive (R87.810)
• Vaginal high-risk HPV positive (R87.811)
• Cervical Pap with evidence of malignancy (R87.614)
• Vaginal Pap with evidence of malignancy (R87.624)
• Cervical Pap with other abnormal finding (R87.619)
• Vaginal Pap with other abnormal finding (R87.628)

C) Abnormalities of the vagina, cervix, uterus, ovaries or adnexa are found on exam:

• Routine gynecological exam with abnormal finding (Z01.411)
• An additional code is needed for the abnormal finding

D) The patient is experiencing signs or symptoms that might reasonably be related to a gynecological exam:

• Menorrhagia (N92.0)
• Metrorrhagia (N92.1)
• Post-coital bleeding (N93.0)
• Irregular menstruation, unspecified (N92.6)
• Other irregular menstruation (N92.5)
• Postmenopausal bleeding (N95.0)
• Inflammatory disease cervix (N72)
• Mild cervical dysplasia - CIN I (N87.0)
• Moderate cervical dysplasia - CIN II (N87.1)

2) Screening Pap tests are done in the absence of signs, symptoms or history (see ICD-10 Coding Guidelines, Ch. 21.c.5).

They may fall into either a no-risk or high-risk category. A no-risk patient is eligible for routine screening once a year or every two years under Medicare.

A Pap test is considered screening if it meets any of the following criteria:

• Physician recommends the procedure
• Patient is of childbearing age
• No Pap test in the past three years

 Screening Pap tests have several codes to choose from:

• Routine gynecological exam without abnormal findings (Z01.419)
• Routine gynecological exam with abnormal findings (Z01.411)
• Cervical Pap test (Z12.4)
• Vaginal Pap test (Z12.72)
• Pap test other genitourinary sites (Z12.79)

A Medicare high-risk patient may receive a Pap test on an annual basis. High-risk (Z91.89) factors include:

• Early onset of sexual activity (under 16 years of age)
• Multiple sex partners (5 or more)
• History of sexually transmitted disease
• Fewer than 3 negative Pap tests in 7 years
• DES exposure during pregnancy (P04.8)

3) Additional ICD-10 codes needed (MANDATORY)

If a vaginal Pap test or additional testing is being performed at the time of the Pap test, additional codes are necessary to support the medical necessity for each test.

Instructions under Z01.411 and Z01.419 (routine gynecological exam with or without abnormal findings) indicate that the codes include a cervical Pap screening and instruct us to add additional codes for HPV screening and/or a vaginal Pap test. The instructions under Z01.411 (routine GYN exam with abnormal findings) state additional codes must be used to indicate any abnormal findings.

Some additional codes that may be needed for additional non-symptomatic screenings include:

• Screening for malignant neoplasm of vagina (Z12.72)
• Screening for HPV (V11.51)
• Screening for chlamydia (Z11.8)
• Screening for STD (Z11.3)
• Exposure to venereal disease (Z20.2)
• Exposure to other viral diseases (Z20.828)

 Some additional codes that may be needed for additional testing when the patient presents with symptoms include:

• Pelvic or perineal pain (R10.2)
• Dyspareunia (N94.1)
• Vaginitis, acute (N76.0)
• Vaginitis, chronic (N76.1)
• Vulvitis, acute (N76.2)
• Vulvitis, chronic (N76.3) 

 Note: Medicare will only cover HPV screening (in combination with a PAP screening) for women between the ages of 30-65 once every five (5) years. Screening beyond this may result in the patient being responsible for the charges. For Medicare screening guidelines see CAG-00442N, MM9434 and NCD 210.2.1 for HPV screening. See MM9719 for screening for sexually transmitted diseases. See MLN booklet “Screening Pap Tests and Pelvic Examinations” for guidelines on Pap tests.

4) Pregnancy and the Pap test.

When a Pap test is being performed in connection to routine pregnancy care, the first ICD-10 code should indicate that the encounter is for routine pregnancy care. Under ICD-10, we are required to select diagnosis codes that indicate the trimester. Trimesters are defined as follows:

 1st trimester: less than 14 weeks 0 days2nd trimester: 14 weeks 0 days to 27 weeks 6 days

3rd trimester: 28 weeks 0 days to delivery