Wiki Z01.411 vs Z01.419

[bharathiT]

Z01.411 -Encounter for gynecological examination (general) (routine) with abnormal findings.
Z01.419- Encounter for gynecological examination (general) (routine) without abnormal findings.

Patient present routine well women visit examination with E11.65(Type 2 diabetes mellitus ,poorly controlled).

In this scenario, want to consider as abnormal finding or not ?

Any gynecology related new condition or any OB-GYN related worsening condition means consider as abnormal finding?

 

[thomas7331]

As I understand it, chronic diseases or pre-existing conditions are not considered a 'finding'. A finding would be something abnormal that was identified during the routine encounter.

 

[mitchellde]

I agree with Thomas, it must be an abnormality discovered in the encounter by the provider, this can be a new problem or it can be an exacerbation of an existing problem, not a pre existing condition that is stable or a new problem/symptom the patient complains of.

 

[bharathiT]

Yes. thanks for the answer, my doubt is DM poorly controlled. In this case we consider this as exacerbation of an existing problem to code Z01.411?.

An examination with abnormal findings refers to a condition/diagnosis that is newly identified or a change in severity of a chronic condition (such as uncontrolled hypertension, or an acute exacerbation of chronic obstructive pulmonary disease) during a routine physical examination.

 

[thomas7331]

You'll need to look at your provider's documentation for your encounter and make a decision as to whether it supports that this is a finding during the encounter or not. Doubt is always a part of coding work - you'll never be able to completely eliminate uncertainty in coding. No matter how well you know the rules, there will still always be different interpretations and opinions about what is the right code for a given record but at some point you just have to make your code choice a be prepared to defend it. But that's a good thing too - if there was always a clear right answer, then machines could do this work and coders wouldn't be needed any more.