Encntr for gyn exam (general) (routine) w abnormal findings

This code signifies a routine or general gynecological examination where the healthcare provider identifies one or more abnormal findings. These abnormalities could range from palpable masses, unusual discharge, or atypical visual observations of the reproductive organs. It indicates that the examination was not solely for screening but also involved the discovery of a clinical concern.

Use this code when a patient presents for a regular gynecological check-up, such as an annual exam or a well-woman visit, and the clinician documents an abnormal finding during that encounter. This includes situations where a Pap test result is abnormal, or a physical examination reveals a suspicious lesion or tenderness. It is appropriate when the primary reason for the visit was routine, but the outcome included a new abnormal discovery.

• Always sequence this code as the primary diagnosis if the abnormal finding was discovered during a routine exam and is the focus of the encounter.
• Code the specific abnormal finding(s) discovered during the examination as secondary diagnoses to provide further clinical detail.
• Do not use this code if the patient presented specifically for evaluation of a known or suspected gynecological abnormality; in such cases, code the specific condition.