E&M code for Well Woman Exam
If a complete general physical exam is performed, use preventive medicine E&M codes 99384–99387 for new patients and 99394–99397 for established patients. When a patient is seen for a physical and has a separately identifiable symptom, condition, or disease that requires significant time or resources, it should be documented and coded separately. Append the modifier -25 to the appropriate office E&M (99201 – 99215). When a patient is seen for a physical and a screening Pap smear is collected at the time, code the E&M and Pap collection HCPCS code Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory).
Diagnosis to report for Well Women exam
V72.31 Routine gynecological examination that includes with or without Papianicolaou cervical smear
Use the below listed codes in addition to V72.31 when appropriate:
V67.01 Vaginal Pap Smear s/p hysterectomy for malignant condition
V76.2 Cervical Pap Smear (Routine)
V76.47 Vaginal Pap Smear s/p hysterectomy for non-malignant condition
V76.49 Special screening for malignant neoplasm, other sites.
V15.89 Other specified personal history presenting hazards to health. (Used for women considered to be at high-risk for cervical cancer. Examples would be screenings for patients with early onset of sexual activity, patients exposed to DES in the womb, patients with more than five sexual partners in a lifetime, and patients who have had a sexually transmitted disease.)
V45.77 Acquired absence of the uterus.
Pap smears completed on women who have had previous cancer of the female genital tract are diagnostic, not screening, Pap smears. They are for a medically necessary reason, regardless of the presence or absence of symptoms. The appropriate personal history diagnosis code is reported.
For Example: V67.01 would be used for diagnostic vaginal pap smear s/p hysterectomy for malignant condition (use additional codes for acquired absence of genital organs V45.77_x)
Abnormal Followed by Normal Pap
If a woman has an abnormal Pap smear and then a follow-up Pap smear is normal, two more Pap smears are usually done to confirm the normal result. These encounters will be coded with ICD V72.32.