Wiki ICD-10 Routine Exam with abnormal findings

[dmgomez]

We are having a group discussion on Routine Exam with abnormal findings. A child is at the physicians office for a routine exam, during the routine exam it is discovered the child has an earache. We have reviewed Section III, Part B, page 28 in the ICD-10 coding guidelines. which states abnormal findings (laboratory, X-ray, pathologic and other diagnostic results). So we believe that according to guidelines this does not qualitfy as an abnormal findings. We would like your view on this matter.

 

[mitchellde]

Was the patient symptomatic? If so then for ICD-10 CM you code the symptom only. If the patient was asymptomatic and an infection is discovered on diagnostic exam the yes I call this an abnormal finding. It is a finding by the provider that was not suspected due to a normal healthy appearing patient. The exam constitutes a diagnostic exam

 

[dmgomez]

Thanks Debra!