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ICD Hub / Factors influencing health status or contact with health services (Z00–Z99) / QA00.9 - Gynaecological examination
ICD-11

ICD-11 Codes
for QA00.9 - Gynaecological examination
Teodor Jurukovski January 1, 1970
Fact checked by: Teodor Jurukovski
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Exploring Different Terms for Gynaecological Examination

In clinical practice and medical documentation, the ICD-11 code QA00.9 for Gynaecological examination may be referred to by various terms. These include:

  • Annual gynaecological examination
  • Routine pelvic examination
  • General gynaecological check-up
  • Periodic pelvic examination
  • Cervical Papanicolaou smear as part of routine gynaecological examination
  • Routine cervical Papanicolaou smear

Understanding the ICD-11 Code for Gynaecological Examination

The ICD-11 code QA00.9 represents a Gynaecological examination. This classification is used for encounters where an individual contacts health services for a general examination or investigation, specifically concerning gynaecological health, in the absence of any current complaint or a previously reported diagnosis. It signifies a routine check-up or screening performed to assess general well-being rather than to investigate specific symptoms or established conditions.

Accurate Documentation for ICD-11 Code QA00.9

Accurate documentation is crucial when using the ICD-11 code QA00.9. This code is designated for situations where the primary reason for the healthcare encounter is a general gynaecological examination without any reported symptoms or diagnosed illness. It falls under Chapter 24, "Factors influencing health status or contact with health services," specifically within the category of contact with health services for examination or investigation. This code is not used to document a specific disease or condition but rather the purpose of the visit.

When to Seek Medical Advice vs. Routine Check-ups

The ICD-11 code QA00.9 is specifically for routine gynaecological examinations when there are no symptoms or diagnosed conditions. Patients should seek medical advice and consult a healthcare professional for a different diagnostic code if they experience any of the following:

  • Unusual vaginal bleeding or discharge
  • Pelvic pain or discomfort
  • Changes in menstrual cycles
  • Lumps or masses
  • Pain during intercourse
These symptoms indicate a need for investigation into a specific condition, rather than a general examination.

When coding gynaecological encounters, it is important to distinguish QA00.9 from other related ICD-11 codes. For instance, routine examinations for contraceptive maintenance are coded under QA21.5, and pregnancy examinations or tests fall under QA040. Special screening examinations for cervical neoplasms are coded as QA09.4. The QA00.9 code is explicitly for general examinations without a reported diagnosis or complaint, and it excludes specific screening or maintenance services.

Reportability and Billing for Routine Gynaecological Exams

The ICD-11 code QA00.9, Gynaecological examination, is reportable for healthcare encounters that fit its definition: a general examination without a specific complaint or diagnosis. Its billability is subject to payer policies, but it represents a distinct type of healthcare service. Providers use this code to signify that the patient presented for a routine gynaecological check-up, which may include screening tests. It is essential to ensure that the documentation supports the use of this code for billing purposes, reflecting a service provided for general health assessment.

Frequently asked questions

What is the ICD-11 classification meaning of code QA00.9?
ICD-11 code QA00.9 signifies a gynaecological examination conducted for individuals without a current complaint or a reported diagnosis.
In what context is ICD-11 code QA00.9 utilized for documentation?
This code is used for health encounters where a gynaecological examination is performed, but no specific disease, disorder, or injury is identified or reported at the time of the encounter.
Where does ICD-11 code QA00.9 fit within the ICD-11 classification structure?
ICD-11 code QA00.9 is categorized under Chapter QA00-QA00, 'Factors influencing health status or contact with health services,' specifically for examinations without a reported diagnosis.
Can ICD-11 code QA00.9 be used if a gynaecological issue is identified during the examination?
No, ICD-11 code QA00.9 is exclusively for examinations where no complaint or reported diagnosis is present. If a gynaecological issue is identified, a different, more specific ICD-11 code would be assigned.
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