What is included in an in person annual gynecologic exam?

If you are coming for an annual Pap smear exam, please note that if you have insurance that many insurance plans are quite particular about providing one exam per year.

Your annual exam consists of cervical and breast cancer screening, STD testing and preventative birth control discussions. However many patients discuss this and much more during the course of their “annual exam” but do not realize that anything else discussed with the provider during the annual exam can be considered a separate evaluation service from your annual exam and can incur a separate copay.

Frequently Asked Questions (FAQ)

1. Why does my insurance only allow one annual a year? And why does it only cover certain things?

Your coverage for your care is determined by your level of benefits which is a contract between you and your insurance company. Our office is bound by the rules of these contracts. For most plans annual gynecologic exams are considered preventative care and these visits do not require a copay. However because these are preventative care visits if anything is discussed other than preventive gynecologic care (for example menopause, discharge, abnormal bleeding, fibroids, cysts, etc.) then the visit is considered to have a separate evaluation component which your insurance can carve out of your preventative care. This "carve out" is subject to the level of benefits of your policy and may or may not require an additional copay at the time of service. Because these visits are considered preventative care and national scientific bodies give recommendations to insurance companies about how often these visits should occur your insurance determines how often you are eligible for preventative care. For most plans this includes one "annual" exam per year. However the physician’s job is to provide you with complete care at every visit and therefore may discuss other things with you and order evaluations to diagnose and treat other symptoms during the course of the exam based on your complaints. If you want only preventative care and not complete care (that is you would like to have just your preventative care and come back at a separate time to discuss anything else including hormonal symptoms) then we recommend that you specifically state this to the physician when you are asked if anything else is going on or if you are having any other issues. If the physician finds something during the course of your exam depending on what that finding is typically an evaluation and management service is completed at that time because ethically we can’t ignore findings present at a visit despite what your insurance contract may say in regards to a copayment.

2. What codes are used for billing for the annual exam?

Typically if only an annual exam is provided (again no other discussion, lab review, medications refilled or other non preventative prescriptions or orders provided, etc.) the diagnosis code that is one of the following:

Depending on the circumstances, either Z01.411, Encounter for gynecological examination (general) (routine) with abnormal findings, or Z01.419, Encounter for gynecological examination (general) (routine) without abnormal findings, may be used as the ICD-10-CM diagnosis code for the annual exam performed by an obstetrician–gynecologist.

The CPT codes for this type of service is age dependent:

The patient preventive medicine services codes 99381-99397 include an age- and gender-appropriate physical exam.