Demographics
Name |
Age |
Gender |
Race |
Reason for Visit |
Time |
GYN encounters
Z01.411 |
GNY exam w/ abnormal findings |
Z01.419 |
GNY exam w/o abnormal findings |
Documentation Stuff
preventive cares discussed |
encouraged adequate calcium intake; calcium counts handout |
pap completed; tolerated well |
explained notification of results |
safe sex practices reviewed |
STD prevention |
vulvar care |
self-breast exams |
E&M
99384 new |
99394 est |
12-17 years |
99385 new |
99395 est |
19-39 years |
99386 new |
99396 est |
40-64 years |
99387 new |
99397 est |
65+ years |
|
|
Procedure Codes
G8510 |
screen depression negative |
88142 |
cytopathology, thin prep. |
ICD
Z12.4 |
cervical cancer screening |
Z12.31 |
breast cancer screening |
Z13.820 |
osteoporosis screening |
Z13.89 |
depression screening negative |
Z11.3 |
STD screening |
Z30.431 |
intrauterine device surveillance |
Z30.41 |
OCP surveillance |
Z13.89 |
irregular bleeding |
L30.4 |
intertriginous dermatitis associated with moisture |
N89.8 |
vaginal irritation |
R32 |
urinary incontinence |
N89.9 |
noninflammatory disorder of vagina, unspesified |
Medicare GYN screening
G0101 |
cervical or vaginal cancer screening, pelvic and breast exam |
Q0091 |
collection of Pap Smear |
|
|
Pregnancy
Z34.00* Encounter for supervision of normal first pregnancy, unspecified trimester |
Z34.01 Encounter for supervision of normal first pregnancy, first trimester |
Z34.02 Encounter for supervision of normal first pregnancy, second trimester |
Z34.03 Encounter for supervision of normal first pregnancy, third trimester |
Z34.80* Encounter for supervision of other normal pregnancy, unspecified trimester |
Z34.81 Encounter for supervision of other normal pregnancy, first trimester |
Z34.82 Encounter for supervision of other normal pregnancy, second trimester |
Z34.83 Encounter for supervision of other normal pregnancy, third trimester |
Z34.90* Encounter for supervision of normal pregnancy, unspecified, unspecified trimester |
Z34.91* Encounter for supervision of normal pregnancy, unspecified, first trimester |
Z34.92* Encounter for supervision of normal pregnancy, unspecified, second trimester |
Z34.93* Encounter for supervision of normal pregnancy, unspecified, third trimester |
E66.09 Obesity
General: obese |
GI: abd. soft, obese |
Anus/ perineum: exam limited by body habitus |
|
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