Well-woman Exam Guidelines 2021

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Initial Preventive Physical Exam

MEDICAL CODING ICD-10-CM GUIDELINES LESSON – 1.A – Coder explanation and examples for 2021

The Initial Preventive Physical Exam , also known as the Welcome to Medicare Preventive Visit, promotes good health through disease prevention and detection. We pay for 1 patient IPPE per lifetime no later than the first 12 months after the patients Part B benefits eligibility date.

HHS Pain Management Best Practices Inter-Agency Task Force Report has more information.

7.Screen for potential substance use disorders

Review the patients potential SUD risk factors and, as appropriate, refer them to treatment. You can use a screening tool, but its not required. National Institute on Drug Abuse Screening and Assessment Tools Chart has screening and assessment tools.

8. Educate, counsel, and refer based on previous components

Based on the review and evaluation services results in the previous components, provide appropriate education, counseling, and referrals.

9. Educate, counsel, and refer for other preventive services

Include a brief written plan, like a checklist, for the patient to get:

  • Once-in-a-lifetime screening electrocardiogram , as appropriate
  • Appropriate screenings and other preventive services we cover

HHS Pain Management Best Practices Inter-Agency Task Force Report has more information.

12. Screen for potential substance use disorders

1. Review and update Health Risk Assessment

  • Get patient self-reported information
  • You or the patient can update the HRA before or during the AWV it shouldnt take more than 20 minutes
  • At a minimum, collect this information:
  • Screening For Human Immunodeficiency Virus Infection

    The Women’s Preventive Services Initiative recommends prevention education and risk assessment for human immunodeficiency virus infection in adolescents and women at least annually throughout the lifespan. All women should be tested for HIV at least once during their lifetime. Additional screening should be based on risk, and screening annually or more often may be appropriate for adolescents and women with an increased risk of HIV infection.

    Screening for HIV is recommended for all pregnant women upon initiation of prenatal care with retesting during pregnancy based on risk factors. Rapid HIV testing is recommended for pregnant women who present in active labor with an undocumented HIV status. Screening during pregnancy enables prevention of vertical transmission.

    What Is Our Healthy Male Program

    Similar to a HFSP, a healthy male standardized patient is a male standardized patient who acts as a physical exam model, allowing learners to perform rectal and/or genital exams under the instruction of a tutor/facilitator. These SPs are also not health professionals but are extremely comfortable with their bodies and providing the opportunity for a patient experience while practicing clinical skills.

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    What Is A Well Woman Exam And How To Prepare For It

    The rate of advancement, research and discovery in the medical field has not only improved the quality of life that we experience but has led to the curing of diseases, saving lives and preventing conditions unlike ever before. Aside from the incredible work done in the treatment of diseases and conditions, the preventative side of the field has come a long way as well.

    Earlier detection and screening for countless health concerns now have doctors and patients armed with the invaluable asset of time on their side and advanced information from the tests and screenings performed. Annual physicals are a recommended measure for all as a strong step towards preventative care. For women, a Well Womans Exam includes sex-specific tests to help detect conditions early or catch them at the beginning of onset.

    Summary Of Recommendations For Clinicians And Policy

    Need is everywhere. But what is new is the sense of desperation, which ...

    The Canadian Task Force on Preventive Health Care has adopted the American College of Physicians 2014 recommendation on the use of pelvic examinations to screen for cancer , pelvic inflammatory disease, and other gynecologic conditions.The recommendation applies to screening pelvic examination in asymptomatic, nonpregnant, adult women. However, it should be noted that pelvic examination is appropriate in other clinical situations, such as for diagnosis of gynecological conditions when women present with symptoms or for follow up of a previously diagnosed condition.

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    Schedule Your First Well Woman Exam

    We know that many women feel anxious about their annual well woman exams, especially if its your first. At Walnut Hill OB/GYN, we try to make your first well woman exam comfortable and easy, so we can detect irregularities and concerns as early as possible. Contact us today at 363-7801 to schedule your annual well-woman exam.

    Counseling For Sexually Transmitted Infections

    The Women’s Preventive Services Initiative recommends directed behavioral counseling by a health care provider or other appropriately trained individual for sexually active adolescent and adult women at an increased risk for sexually transmitted infections .

    The Women’s Preventive Services Initiative recommends that health care providers use a woman’s sexual history and risk factors to help identify those at an increased risk of STIs. Risk factors may include age younger than 25, a recent history of an STI, a new sex partner, multiple partners, a partner with concurrent partners, a partner with an STI, and a lack of or inconsistent condom use. For adolescents and women not identified as high risk, counseling to reduce the risk of STIs should be considered, as determined by clinical judgement.

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    Screening For Gestational Diabetes Mellitus

    The Women’s Preventive Services Initiative recommends screening pregnant women for gestational diabetes mellitus after 24 weeks of gestation in order to prevent adverse birth outcomes. Screening with a 50-g oral glucose challenge test is preferred because of its high sensitivity and specificity.

    The Women’s Preventive Services Initiative suggests that women with risk factors for diabetes mellitus be screened for preexisting diabetes before 24 weeks of gestationideally at the first prenatal visit, based on current clinical best practices.

    Coding & Billing Guidelines

    What to Expect from a Well Woman Exam

    Blue Cross Blue Shield of North Dakota has identified an increase in providers unbundling Preventive Evaluation and Management and/or Gynecological Screening services. The claims reviewed include additional service which are inherent components of the codes such as pap smear collection or digital rectal examinations. The below billing guidelines are provided to educate providers on correct billing.

    E/M Service & Gynecological Exam

    When a physician performs a systemic physical examination as part of an annual gynecological examination and provides an unrelated, separately identifiable E/M on the same day both services may be billed. The appropriate medical E/M office visit code may be reported with modifier 25 in addition to the gynecological examination . If the reported service do not meet the component requirements of the codes billed the services should not be billed.

    Preventive E/M & Gynecological Exam

    When a physician performs an annual gynecological examination and a preventive examination on the same day, there is significant overlap of the components of these two services . However, the preventive examination may include services beyond the scope of the gynecological exam, such as counseling and anticipatory guidance, risk factor intervention, age-appropriate lab work, and certain screening tests . Providers should only report the Preventive E/M when rendering a gynecological and systemic preventive annual E/M service.

    Preventive E/M & Digital Rectal Examination

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    Ippe Awv & Routine Physical: Know The Differences

    Medicare Preventive Services educational tool has more information.

    No. The IPPE isnt a routine physical that some older adults may get periodically from their physician or other qualified non-physician practitioner . The IPPE is an introduction to Medicare and covered benefits, and focuses on health promotion, disease prevention, and detection to help patients stay well. We encourage providers to inform patients about the AWV and perform such visits. The Social Security Act explicitly prohibits Medicare coverage of routine physical exams.

    No. The AWV isnt a routine physical that some older adults may get periodically from their physician or other qualified NPP. We dont cover routine physical exams.

    No. The IPPE and AWV dont include clinical lab tests, but you may make appropriate referrals for these tests as part of the IPPE or AWV.

    No. We waive the coinsurance, copayment, and Part B deductible for the IPPE . Neither is waived for the screening electrocardiogram .

    No. We waive the coinsurance, copayment, and Part B deductible for the AWV.

    An eligible 2022 patient who hasnt had an IPPE and whose initial enrollment in Part B began in 2022, can get an IPPE in 2023 if its within 12 months of the patients first Part B enrollment effective date.

    We suggest providers check with their MAC for available options to verify patient eligibility. If you have questions, find your MACs website.

    American Cancer Society Guidelines For The Early Detection Of Cancer

    Screening tests are used to find cancer before a person has any symptoms. Here are the American Cancer Society’s recommendations to help guide you when you talk to your doctor about screening for certain cancers.

    Health care facilities are providing cancer screening during the COVID-19 pandemic with many safety precautions in place. The American Cancer Society Get Screened campaign encourages people to start or restart their recommended cancer screenings. Regular screenings can help find and treat pre-cancers and cancers early, before they have a chance to spread. Visit Get Screened to learn about screening tests and what you can do to get on track with a cancer screening schedule thats right for you.

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    Screening For Urinary Incontinence

    The Women’s Preventive Services Initiative recommends screening women for urinary incontinence annually. Screening should ideally assess whether women experience urinary incontinence and whether it impacts their activities and quality of life. The Womens Preventive Services Initiative recommends referring women for further evaluation and treatment if indicated.

    The Women’s Preventive Services Initiative recommends screening women for urinary incontinence as a preventive service. Factors associated with an increased risk for urinary incontinence include increasing parity, advancing age, and obesity however, these factors should not be used to limit screening.

    Several screening tools demonstrate fair to high accuracy in identifying urinary incontinence in women. Although minimum screening intervals are unknown, given the prevalence of urinary incontinence, the fact that many women do not volunteer symptoms, and the multiple, frequently-changing risk factors associated with incontinence, it is reasonable to conduct annually.

    Checklist For Women In Their 60s & Older

    • Pap test and pelvic exam: Based on the best available guidelines, the Pap test is not routinely recommended after age 65. The decision should be made between the woman and her clinician and based on her own history.
    • Routine blood tests and lipid screening: At least once a year or as often as needed. Varies for each individual and depends on family history of colon cancer and colonoscopy results. For most people who are at average risk, a colonoscopy is recommended once every 10 years after turning 45.
    • Osteoporosis screening: Women 65 and older with normal bone mass should have a bone mineral density test every 15 years. More frequent testing is recommended for women with certain risk factors for osteoporosis, such as smoking, alcoholism, history of hip fracture in a parent, or rheumatoid arthritis.
    • Skin cancer screening: Once a year. More frequently if there is a family history of skin cancer or a history of prolonged sun exposure.
    • Cardiology screening: At least once a year or as needed, especially if you are African American, have had preeclampsia or high blood pressure while pregnant, or have a family history of heart disease.

    Experts Take: If youre over 65 and would like to continue with regular Pap smears because of HPV risk or other concerns, speak with your OB-GYN so that they can evaluate your risks and you can come up with a plan together, says Dr. Rosser.

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    *criteria For Selective Screening

    1. Cardiovascular Disease and Colorectal Cancer prevention with Asprin: Calculated 10-year risk of a CVD event 10% not at increased risk for bleeding have a life expectancy of at least 10 years and are willing to take low-dose aspirin daily for at least 10 years.

    2. Diabetes screening and management: Overweight or obese for age 40-70 years previous gestational diabetes but not previously diagnosed with diabetes mellitus when not pregnant for age 13 years.

    3. Folic acid supplementation: Sexually active and planning or capable of pregnancy.

    4. Healthful diet and physical activity counseling: Overweight or obese and have additional CVD risk factors . Specific anticipatory guidance for ages 13-17 may be found in the Bright Futures Guidelines.

    5. Lipid Screening:Familial dyslipidemia, risk factors, or high-risk conditions for age 13-16 years universal screening once between age 17-21 years clinical judgement for age 22-39 years.

    6. Osteoporosis screening: 10-year fracture risk equivalent to an average-risk 65-year old woman based on specific risk factors .

    7. Statin use to prevent CVD: Age 40 to 75 years one or more CVD risk factors and calculated 10-year risk of a CVD event 10%.

    8. Urinary incontinence screening: Screen all women age 18 and older and younger women if postpartum.

    14. Syphilis screening: Women with HIV high prevalence communities or populations history of incarceration exchanging sex for money or drugs.

    Suggested Citation


    Preparing Eligible Patients For The Annual Wellness Visit

    Providers can help eligible patients prepare for their AWV by encouraging them to bring this information to their appointment:

    • Medical records, including immunization records
    • Detailed family health history
    • Full list of medications and supplements, including calcium and vitamins, and how often and how much of each they take
    • Full list of current providers and suppliers involved in their care, including community-based providers , and behavioral health specialists

    Part B covers an AWV if performed by a:

    • Qualified non-physician practitioner
    • Medical professional , or a team of medical professionals that a physician directly supervises

    When you provide an AWV and a significant, separately identifiable, medically necessary Evaluation and Management service, we may pay for the additional service. Report the additional CPT code with modifier 25. That portion of the visit must be medically necessary and reasonable to treat the patients illness or injury or to improve the functioning of a malformed body part.

    You can only bill G0438 or G0439 once in a 12-month period. G0438 is for the first AWV and G0439 is for subsequent AWVs. Remember, you must not bill G0438 or G0439 within 12 months of a previous G0402 billing for the same patient. We deny these claims with messages of, Benefit maximum for this time period or occurrence has been reached and Consult plan benefit documents/guidelines for information about restrictions for this service.


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    Checklist For Girls In Their Teens

  • Human papillomavirus vaccine: The HPV vaccine protects against developing certain cancers later in life, such as cervical cancer. The Centers for Disease Control and Prevention recommends all boys and girls get their HPV vaccine at age 11 or 12.
  • Blood pressure screening: This assesses for risk factors such as diabetes, obesity, and heart disease. While it might seem early to discuss these issues, in my experience, its better to start these conversations sooner so that girls are knowledgeable about taking care of their health and their bodies, says Dr. Rosser. The more you talk about it, the more they will listen. Learning is repetition.
  • Lipid screening: Once, beginning in late adolescent years. This blood test checks the amount of cholesterol and triglycerides.
  • Experts Take: These health visits are also an opportunity to talk about alcohol, drug use, and tobacco use as well as topics such as anxiety and depression, adds Dr. Rosser.

    Comprehensive History And Physical Examination

    MEDICAL CODING ICD-10-CM GUIDELINES LESSON – 1.B – Coder explanation and examples for 2021

    A comprehensive history is one of the most important aspects of a well-woman visit. This history includes symptoms medications allergies and medical, surgical, family, social, and gynecologic history, including questions on reproductive, sexual, and mental health . Taking a comprehensive history will inform if certain components of the physical examination, including breast or pelvic examination, are indicated at that visit and will inform shared decision making for these examinations. The American College of Obstetricians and Gynecologists recommends that pelvic and breast examinations be performed when indicated by medical history or symptoms 78. Some specific topics that are sometimes overlooked, but that should be addressed at well-woman visits throughout the lifespan, include bone health, vulvovaginal symptoms, and sexual health.

    Family history should be used as a risk assessment tool and should be completed and updated regularly to ensure the most comprehensive assessment of a womans personal risk factors 9. For example, the family history may be used to identify a woman at increased risk of cancer, allowing her to be referred for genetic testing, counseling, or both, and for further preventive care as indicated.

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    Frequently Asked Questions Expand All

  • When is a pelvic exam not needed?

    A pelvic exam is not needed to screen for sexually transmitted infections . You also dont need one to get birth control, other than an IUD.

    Adolescents usually dont need a pelvic exam at their first gynecologic visit unless they are having problems.

  • Do I need an annual pelvic exam if I dont have any symptoms?

    There is not much research on the usefulness of annual pelvic exams for women who arent pregnant, experiencing symptoms, or at risk for gynecological conditions. The American College of Obstetricians and Gynecologists recommends women have pelvic exams only when they have symptoms or have a medical history that requires it.

    Ultimately, you and your ob-gyn or other health care professional should make this decision together. Discuss your medical history and the risks and benefits of a pelvic exam.

  • What are the benefits of a routine pelvic exam?

    The potential benefits of a routine pelvic exam include:

  • Possible early detection of treatable conditions, such as infections or cancer

  • Detection of other problems, such as changes to the skin in your pelvic area

  • A better understanding of your body

  • Reassurance about your sexual and reproductive health

  • What else should I know before getting a pelvic exam?

    Pelvic exams can be triggering or painful for survivors of sexual abuse. If this is true for you, let your ob-gyn know. The following may help make the pelvic exam easier:

  • Your ob-gyn should always ask permission before touching you.

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