Coding a patient’s symptoms or conditions varies across specialties. For OB GYNs in particular, the ICD-10 codes they often find themselves relying on are rarely used in any other form of medicine. Due to their focus on women’s health, these codes are unlikely to crop up in an emergency room or a cardiologist’s office.
Here are 10 ICD-10 codes most OB/GYNs will rely on during their careers.
Z01.419 – Encounter for gynecological examination (general) (routine) without abnormal findings
This code covers are routine visit from a patient to their OB/GYN. According to most industry experts, women between the ages of 21 and 29 should see their gynecologist at least once a year. Women ages 35 to 65 who have had negative Pap test results only need get a new test every 5 years, where as women 65 and older do not need such screenings at all.
Z12.31 – Encounter for screening mammogram for malignant neoplasm of breast
Given that 1 in 8 US women—about 12.4 percent—will develop invasive breast cancer in their lifetimes, it’s important to get screened regularly. Most OB/GYNs offer such screenings as a normal part of a routine check-up.
N80.9 – Endometriosis, unspecified
The stigma surrounding endometriosis has been something of a hot button issue lately, with many healthcare providers and ad campaigns centered around educating women about the diseases and encouraging them to speak up. Doctors are able to provide counseling and pain relief to individuals facing this diagnosis.
Z34.01 – Encounter for supervision of normal first pregnancy, first trimester
This code is exactly what it sounds like—a patient has come into their gynecologist to be examined during their first trimester of pregnancy.
099.011 – Anemia complicating pregnancy, first trimester
Especially for individuals suffering from anemia before they’re pregnant, the risk of anemia developing during a pregnancy is increased. There are three types of pregnancy-related anemia: iron-deficiency anemia, folate-deficiency anemia, and Vitamin B12 deficiency. A patient’s provider can administer blood tests to help determine which version she has, and can recommend treatment accordingly.
V25.5 – Encounter for contraceptive management, insertion of implantable subdermal contraceptive
Z30.018 – Encounter for initial prescription of other contraceptives
There are a wide variety of birth control methods available in today’s market. An IUD is referenced in this first code, and must be implanted by a medical professional. More traditional forms of birth control include pills and shots, which can be prescribed during a visit and then acquired according to a patient’s schedule.
N97.9 – Female infertility, unspecified
Roughly 10 percent of women ages 15 to 44 have difficulty getting pregnant or staying pregnant. There are numerous causes behind female fertility, and a OB/GYN can help identify—and potentially resolve—said issue.
Z11.3 – Encounter for screening for infections with a predominantly sexual mode of transmission
The CDC reported that rates of syphilis, gonorrhea and chlamydia have climbed to record highs, following 4 consecutive years of growth. OB/GYNs are equipped to screen, test, and treat STDs, but only if a patient takes the time to make an appointment to be checked out.
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These are just a handful of codes that an OB/GYN can rely on. Their role in women’s health is certainly an invaluable one. If your practice is looking for an alternative Ob Gyn EHR software we offer a full suite of features and integrations to bring your practice into a more efficient and productive state. Additionally, if you're interested in outsourcing medical transcription, we've got you covered there too. We have all the tools and services that allow us to take great care of your practice, so you can take care of your patients.