Encounter for exam of eyes and vision w abnormal findings

This code signifies a patient encounter specifically for an eye and vision examination where the ophthalmologist or optometrist identifies one or more abnormal findings. These findings could range from refractive errors requiring correction to more serious indicators of ocular disease. It indicates that the examination was not entirely normal, necessitating further investigation or management.

Use this code when a patient presents for a routine or screening eye exam, and the provider documents any deviation from normal ocular health or visual acuity. This includes encounters where new or previously undiagnosed conditions are discovered, or when an existing condition is noted during a general eye check-up. It is appropriate when the primary reason for the visit is the examination itself, and abnormal results are found.

• Always sequence this code as the primary diagnosis when the encounter is for the examination and abnormal findings are noted, unless a more specific definitive diagnosis is established.
• Do not use this code if the patient presents for a specific eye condition already known and being treated; in such cases, code the specific condition.
• Ensure the medical record clearly documents the abnormal findings that support the use of this code.