kodex

Kodex

ICD-10-CM
Code

Z01.411

Encounter for gynecological examination (general) (routine) with abnormal findings

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Hierarchy

  • Z00-Z99 Factors influencing health status and contact with health services (Z00-Z99)
    • Z00-Z13 Persons encountering health services for examinations (Z00-Z13)
      • Z01 Encounter for other special examination without complaint, suspected or reported diagnosis
        • Z01.4 Encounter for gynecological examination
          • Z01.41 Encounter for routine gynecological examination
            • Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings
            • Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings

Notes

Z01

  • Codes from category Z01 represent the reason for the encounter. A separate procedure code is required to identify any examinations or procedures performed

Z00-Z13

  • Nonspecific abnormal findings disclosed at the time of these examinations are classified to categories R70-R94.

Z00-Z99

  • Z codes represent reasons for encounters. A corresponding procedure code must accompany a Z code if a procedure is performed. Categories Z00-Z99 are provided for occasions when circumstances other than a disease, injury or external cause classifiable to categories A00-Y89 are recorded as 'diagnoses' or 'problems'. This can arise in two main ways:
  • (a) When a person who may or may not be sick encounters the health services for some specific purpose, such as to receive limited care or service for a current condition, to donate an organ or tissue, to receive prophylactic vaccination (immunization), or to discuss a problem which is in itself not a disease or injury.
  • (b) When some circumstance or problem is present which influences the person's health status but is not in itself a current illness or injury.

Inclusion Terms

Z01.41

  • Encounter for general gynecological examination with or without cervical smear
  • Encounter for gynecological examination (general) (routine) NOS
  • Encounter for pelvic examination (annual) (periodic)

Use Additional

Z01.411

  • code to identify abnormal findings

Z01.41

  • code:
  • for screening for human papillomavirus, if applicable, (Z11.51)
    • Z11.51 Encounter for screening for human papillomavirus (HPV)
  • for screening vaginal pap smear, if applicable (Z12.72)
    • Z12.72 Encounter for screening for malignant neoplasm of vagina
  • to identify acquired absence of uterus, if applicable (Z90.71-)
    • Z90.71 Acquired absence of cervix and uterus

Includes

Z01

  • routine examination of specific system

Excludes 1

Z01.41

  • gynecologic examination status-post hysterectomy for malignant condition (Z08)
    • Z08 Encounter for follow-up examination after completed treatment for malignant neoplasm
  • screening cervical pap smear not a part of a routine gynecological examination (Z12.4)
    • Z12.4 Encounter for screening for malignant neoplasm of cervix

Z01

  • encounter for examination for administrative purposes (Z02.-)
    • Z02 Encounter for administrative examination
  • encounter for examination for suspected conditions, proven not to exist (Z03.-)
    • Z03 Encounter for medical observation for suspected diseases and conditions ruled out
  • encounter for laboratory and radiologic examinations as a component of general medical examinations (Z00.0-)
    • Z00.0 Encounter for general adult medical examination
  • encounter for laboratory, radiologic and imaging examinations for sign(s) and symptom(s) - code to the sign(s) or symptom(s)

Z00-Z13

  • examinations related to pregnancy and reproduction (Z30-Z36, Z39.-)
    • Z39 Encounter for maternal postpartum care and examination

Excludes 2

Z01.4

  • pregnancy examination or test (Z32.0-)
    • Z32.0 Encounter for pregnancy test
  • routine examination for contraceptive maintenance (Z30.4-)
    • Z30.4 Encounter for surveillance of contraceptives

Z01

  • screening examinations (Z11-Z13)

Related Terms