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Wiki ICD-10 Routine Exam with abnormal findings

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dmgomez

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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.
 
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
 
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