Encounter for exam of eyes and vision w/o abnormal findings

This code signifies a routine eye examination performed on a patient who presents with no visual complaints or known ocular conditions. The examination, including vision testing, reveals no abnormalities requiring further diagnostic workup or treatment. It represents a "normal" or "negative" finding for a screening or preventative eye visit.

This code is appropriate for annual or routine eye exams where the patient has no specific symptoms, and the ophthalmologist or optometrist finds no pathology. It is commonly used for preventative care visits, such as a yearly check-up for a healthy individual, or for school/work-related vision screenings that yield normal results.

• Always ensure the medical record explicitly states "no abnormal findings" or similar language to support the use of this code.
• Do not use this code if any ocular condition, even minor, is identified during the examination; instead, code the specific condition(s).
• This code is typically a primary diagnosis for a well-patient encounter, but can be used as a secondary diagnosis if another unrelated condition is being managed.