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2025 ICD-10-CM code Z01.411

Encounter for a routine gynecological examination with abnormal findings.

A corresponding procedure code must accompany a Z code if a procedure is performed.If a procedure is performed in addition to the routine examination, code both the procedure and Z01.411.Non-specific abnormal findings disclosed at the time of these examinations are classified to categories R70-R94.

Medical necessity for the routine gynecological examination is determined by the patient's age, history, and individual risk factors.The medical necessity for the additional code will be determined based on those specific findings.

The clinician is responsible for performing a routine gynecological examination, documenting all findings, and reporting any abnormal findings. Further investigation or treatment may be necessary depending on the specific abnormal findings.Additional codes are required to indicate the abnormal findings.

IMPORTANT: If the findings are normal use Z01.419, If the examination is for suspected conditions, proven not to exist use Z03,if the examination is for administrative purposes, use Z02. Screening examinations are classified Z11-Z13. Use additional code for screening for human papillomavirus, if applicable, (Z11.51),for screening vaginal pap smear, if applicable (Z12.72), to identify acquired absence of uterus, if applicable (Z90.71-)

In simple words: This code is used for a routine gynecological exam where some abnormal findings were discovered.A separate code is needed to specify what the abnormality was.

Encounter for gynecological examination (general) (routine) with abnormal findings. Use additional code to identify abnormal findings.

Example 1: A 30-year-old female patient presents for her annual well-woman exam. During the pelvic examination, the physician palpates an ovarian cyst. Z01.411 is used for the encounter, with an additional code to specify the ovarian cyst., A 45-year-old female patient presents for a routine gynecological check-up.The physician notes an abnormal cervical appearance. A pap smear is performed. Z01.411 would be used with an additional code to describe the abnormal cervical appearance and potentially other codes related to the pap smear result (if available during the encounter). , A 60-year-old female patient who has undergone a hysterectomy presents for a routine follow-up.The exam shows no abnormalities, in this case, Z01.419 would be used since there are no abnormal findings and the patient has had a hysterectomy. Status post hysterectomy for malignant conditions are coded as Z08.

Documentation should include details of the pelvic exam, including visualization, palpation, and any other relevant procedures. Any abnormal findings should be clearly documented, including size, location, and characteristics. This also includes clear indication why the encounter is not related to pregnancy, contraceptive maintenance or any other Z code.

** The code Z01.411 should not be used for screening examinations, such as cervical cancer screening. The chapter guidelines note that non-specific abnormal findings are classified elsewhere (R70-R94).

  • Specialties:Obstetrics and Gynecology, Family Medicine, Internal Medicine
  • Place of Service:Office, Outpatient Hospital, Women's Health Clinic
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