OB/GYN ICD-10-CM codes

The routine gyn exam splits on findings: Z01.419 without abnormal findings, Z01.411 with them (add the code for the finding). Cervical cancer screening performed as part of that exam is bundled into the exam code; a standalone screening Pap is Z12.4, and HPV screening is Z11.51. Abnormal cytology results get their own codes when the patient returns for evaluation: R87.610 for ASC-US, R87.619 when the abnormality is not further specified.

Prenatal supervision uses Z34 for normal pregnancy, split by parity and trimester: Z34.01 to Z34.03 for a first pregnancy, Z34.81 to Z34.83 for subsequent pregnancies, Z34.90 only when nothing more specific is documented. Once any complication is documented, the encounter moves to chapter 15 O codes and Z34 no longer applies; diet-controlled gestational diabetes, for example, is O24.410. Z33.1 (pregnant state, incidental) is reserved for visits unrelated to the pregnancy.

Gynecologic problem visits cluster around bleeding and infection. Distinguish heavy regular cycles (N92.0), irregular menstruation (N92.6), and unspecified abnormal uterine bleeding (N93.9). Vaginitis coding requires the organism when known: B37.31 for acute candidiasis rather than the unspecified N76.0. Contraceptive management is entirely Z30: Z30.011 for initial pill prescription, Z30.430 for IUD insertion, Z30.09 for counseling. Postpartum follow-up is Z39.2.