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A pelvic exam begins with an assessment of the reproductive organs that can be seen without the use of a speculum. [19] Many women may want to 'prepare' for the procedure. [18] One possible reason for delaying an exam is if it is to be done during menstruation, but this is a preference of some patients and not a requirement of the clinician. [18]
The ICD-10 Clinical Modification (ICD-10-CM) is a set of diagnosis codes used in the United States of America. [1] It was developed by a component of the U.S. Department of Health and Human services, [ 2 ] as an adaption of the ICD-10 with authorization from the World Health Organization .
ICD-10 is the 10th revision of the International Classification of Diseases (ICD), a medical classification list by the World Health Organization (WHO). It contains codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. [1]
Although women often undergo well-woman examinations on an annual basis, the interval for this visit and exam will vary depending on the needs of the patient. [3] The purpose of this exam in asymptomatic women is to screen for potential abnormalities, such as sexually transmitted infections, and malignancy. [4] [5]
National adaptations of the ICD-10 progressed to incorporate both clinical code (ICD-10-CM) and procedure code (ICD-10-PCS) with the revisions completed in 2003. In 2009, the US Centers for Medicare and Medicaid Services announced that it would begin using ICD-10 on April 1, 2010, with full compliance by all involved parties by 2013. [19]
CPT coding is similar to ICD-10-CM coding, except that it identifies the services rendered, rather than the diagnosis on the claim. Whilst the ICD-10-PCS codes also contains procedure codes, those are only used in the inpatient setting. [5]
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Although Version:2019 was the last update, and ICD-11 is now available, WHO are still accepting data reported using ICD-10 from member states yet to make the switch to ICD-11. ICD-11 (International classification of diseases, 11th revision) – available for reporting data to WHO since 1 January 2022 [ 5 ]