Encounter for routine child health exam w abnormal findings

This code signifies a preventive health encounter for a child where a health issue or deviation from normal development was identified during the examination. It indicates that while the primary purpose was a routine check-up, the assessment revealed findings requiring further attention or follow-up.

Apply this code when a child presents for a well-child visit, and the physician documents an abnormal finding, such as a new murmur, developmental delay, elevated blood pressure, or an unexpected lab result. It is appropriate when the abnormal finding is discovered during the routine examination itself, rather than being the primary reason for the visit.

• Always sequence this code first, as it represents the primary reason for the encounter.
• Code all specific abnormal findings and conditions identified during the examination as additional diagnoses.
• Do not use this code if the child is presenting for a problem-focused visit, even if a routine element is performed.