What CPT codes are used for annual well-woman visits?

Preventive visits use 99384-99387 (new patient) or 99394-99397 (established) based on age. For patients with additional problems addressed, bill E/M (99213-99215) with modifier 25 plus preventive code. Medicare uses G0101 for pelvic/breast exam and Q0091 for Pap collection. Separate significant problems require documentation distinct from preventive services.

What cervical cancer screening guidelines should be documented?

Document current USPSTF/ASCCP guidelines: age 21-29 Pap alone every 3 years; age 30-65 Pap alone every 3 years, hrHPV alone every 5 years, or co-testing every 5 years. After hysterectomy with cervix removal for benign disease, screening stops. Document screening history, any abnormal results, and rationale for testing interval. Exit screening at age 65 with adequate negative prior screening.

How should breast cancer screening be documented?

Document risk assessment (family history, genetic testing, personal history), mammography status (last date, results, facility), clinical breast exam findings, and patient education. Note screening mammography recommendations (annual vs biennial starting at 40-50 based on guidelines followed). For high-risk patients, document consideration of MRI screening and genetic counseling referral.

What pelvic examination documentation is required?

Document external genitalia (appearance, lesions, discharge), speculum exam (vaginal mucosa, cervix appearance, discharge character, Pap collection if indicated), and bimanual exam (uterine size, position, mobility, tenderness, adnexal masses, CMT). For abnormal findings, document specific location, size, character. If exam deferred or limited, document reason.

Can contraception counseling be billed separately from well-woman visits?

Brief contraception counseling is typically included in preventive visit. Extensive counseling (detailed review of options, risks/benefits, patient education) may warrant separate E/M with modifier 25 if documented as significant separate service. IUD or implant insertion on same day uses device-specific codes (58300 for IUD, 11981 for implant) billed separately from the visit.

Annual GYN Exam Template - Well Woman Visit

OB/GYN — Annual GYN Exam Template

OB/GYN Gynecology Updated: 11/7/2025

The Annual GYN Exam Template is designed for obstetricians, gynecologists, and primary care providers conducting routine well-woman visits including pelvic examination, breast examination, cancer screening, and preventive care counseling. This comprehensive template documents all elements of the annual gynecologic examination including menstrual history, sexual history, contraception review, cancer screening status, physical examination findings, and preventive care recommendations. The template supports appropriate billing for preventive visits (CPT 99395-99397 for established patients) and includes sections for menstrual history and cycle characteristics, sexual history and contraception, cancer screening status including Pap smear, HPV testing, mammography, and colonoscopy, family history of gynecologic cancers, physical examination including breast exam and pelvic exam, assessment of gynecologic health, screening test orders, patient education on preventive care and health maintenance, and scheduling of next annual exam. This template ensures comprehensive well-woman care addressing reproductive health, cancer prevention, and overall health maintenance. Ideal for OB/GYN practices, primary care practices providing gynecologic care, and women's health clinics.

Visit Information

Date of last annual exam: [Date]
Type: Annual GYN exam / Well-woman visit

Menstrual History

Last menstrual period: [Date]
Cycle: Regular / Irregular
Frequency: [Days between cycles]
Duration: [Days of bleeding]
Flow: Normal / Heavy / Light
Dysmenorrhea: None / Mild / Moderate / Severe
Menopause status: Premenopausal / Perimenopausal / Postmenopausal

Sexual History

Sexually active: Yes / No
Contraception: [Current method] / None / Sterilization
STI screening: Last tested [Date], Results: [If known]
Number of partners: [If relevant for screening]

Cancer Screening Status

Pap smear: Last [Date], Results: [Normal / Abnormal / Pending]
HPV testing: Last [Date], Results: [If applicable]
Mammography: Last [Date], Results: [Normal / Abnormal / Pending]
Colonoscopy: Last [Date], Results: [If age-appropriate]

Family History

Gynecologic cancers: [Family history if relevant]
Breast cancer: [Family history]
Other relevant family history

Physical Examination

Vital signs: BP, HR, RR, Temp, Weight, BMI
General: Appearance
Breast exam: Normal / Abnormal findings: [Document]
Pelvic exam:

External: [Normal / Abnormal findings]
Speculum: Cervix appearance, discharge
Bimanual: Uterus size, position, mobility, tenderness
Adnexa: [Normal / Masses / Tenderness]

Assessment

1) Well-woman exam, routine

Gynecologic health: Normal / Concerns: [specify]
Screening status: Up to date / Due for: [specify]

2) [Other diagnoses as applicable]

Plan

1) Screening tests ordered:

Pap smear: [If due]
HPV testing: [If indicated]
Mammography: [If due]
Other: [Specify]

2) Contraception: [Continue current / Change / Initiate]
3) Patient education: Preventive care, breast self-exam, warning signs
4) Follow-up: Return for annual exam in 1 year / Sooner if: [specify]

Patient Instructions

Screening results: [How results will be communicated]
Warning signs: [When to call or return]
Next appointment scheduled.