Wiki What constitutes Z01.411?

KatieO76

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What determines the diagnosis to be abnormal vs. normal? Literature to reference would be perfect!
 
What determines the diagnosis to be abnormal vs. normal? Literature to reference would be perfect!
Abnormal is anything the MD documents as abnormal during the exam. Some have argued that it must be a GYN problem and others that it can be any abnormal finding (like a high blood pressure reading). My take is that it should be gyn related as the code is describing a gyn exam with an abnormal finding. This is nowhere documented, just my best judgement.
 
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