Encounter for general adult medical exam w abnormal findings

This code signifies a routine health check-up for an adult patient where the physician identifies one or more findings outside the normal range. These abnormal findings require further investigation, follow-up, or management, even if the patient is not acutely ill. It indicates that the examination was not entirely unremarkable.

Apply this code when an adult undergoes a general physical examination (e.g., annual physical, preventive health visit) and the provider documents an abnormal finding, such as elevated blood pressure, an unusual mole, or an abnormal lab result. This code is appropriate when the abnormal finding is discovered during the preventive visit itself, prompting further action.

• Always sequence this code first when it is the primary reason for the encounter.
• Always code the specific abnormal finding(s) discovered during the examination as additional diagnoses.
• Do not use this code if the patient presents with a known, pre-existing condition that is the focus of the visit, even if a general exam is performed.