ICD-10-CM Code Z01.411

Encounter for gynecological examination (general) (routine) with abnormal findings

Version 2020 Billable Code Diagnoses For Females Only POA Exempt OB/GYN

Valid for Submission

Z01.411 is a billable code used to specify a medical diagnosis of encounter for gynecological examination (general) (routine) with abnormal findings. The code is valid for the year 2020 for the submission of HIPAA-covered transactions. The ICD-10-CM code Z01.411 might also be used to specify conditions or terms like cervical excitation - finding, cervical excitation absent, finding of sensation of cervix, gynecological examination abnormal, o/e - cervix, o/e - uterus, etc The code is exempt from present on admission (POA) reporting for inpatient admissions to general acute care hospitals.

The code Z01.411 is applicable to female patients only. It is clinically and virtually impossible to use this code on a non-female patient.

The code is commonly used in ob/gyn medical specialties to specify clinical concepts such as general medical and gynecological examinations.

ICD-10:Z01.411
Short Description:Encntr for gyn exam (general) (routine) w abnormal findings
Long Description:Encounter for gynecological examination (general) (routine) with abnormal findings

Tabular List of Diseases and Injuries

The Tabular List of Diseases and Injuries is a list of ICD-10 codes, organized "head to toe" into chapters and sections with guidance for inclusions, exclusions, descriptions and more. The following references are applicable to the code Z01.411:

Use Additional Code

Use Additional Code
The “use additional code” indicates that a secondary code could be used to further specify the patient’s condition. This note is not mandatory and is only used if enough information is available to assign an additional code.
  • code to identify abnormal findings

Index to Diseases and Injuries

The Index to Diseases and Injuries is an alphabetical listing of medical terms, with each term mapped to one or more ICD-10 code(s). The following references for the code Z01.411 are found in the index:


Code Edits

The Medicare Code Editor (MCE) detects and reports errors in the coding of claims data. The following ICD-10 Code Edits are applicable to this code:

  • Diagnoses for females only - Medicare Code Editor detects inconsistencies between a patient’s sex and any diagnosis on the patient’s record, this code applies to FEMALES only .

Synonyms

The following clinical terms are approximate synonyms or lay terms that might be used to identify the correct diagnosis code:

  • Cervical excitation - finding
  • Cervical excitation absent
  • Finding of sensation of cervix
  • Gynecological examination abnormal
  • O/E - cervix
  • O/E - uterus
  • O/E - VE - pelvis not adequate
  • On examination - vaginal examination - cervical excitation absent

Present on Admission (POA)

Z01.411 is exempt from POA reporting - The Present on Admission (POA) indicator is used for diagnosis codes included in claims involving inpatient admissions to general acute care hospitals. POA indicators must be reported to CMS on each claim to facilitate the grouping of diagnoses codes into the proper Diagnostic Related Groups (DRG). CMS publishes a listing of specific diagnosis codes that are exempt from the POA reporting requirement. Review other POA exempt codes here .

CMS POA Indicator Options and Definitions
POA Indicator CodePOA Reason for CodeCMS will pay the CC/MCC DRG?
YDiagnosis was present at time of inpatient admission.YES
NDiagnosis was not present at time of inpatient admission.NO
UDocumentation insufficient to determine if the condition was present at the time of inpatient admission.NO
WClinically undetermined - unable to clinically determine whether the condition was present at the time of inpatient admission.YES
1Unreported/Not used - Exempt from POA reporting. NO

Convert Z01.411 to ICD-9

  • V72.31 - Routine gyn examination (Approximate Flag)

Code Classification

  • Factors influencing health status and contact with health services (Z00–Z99)
    • Persons encountering health services for examinations (Z00-Z13)
      • Encntr for oth sp exam w/o complaint, suspected or reprtd dx (Z01)

Code History

  • FY 2016 - New Code, effective from 10/1/2015 through 9/30/2016
    (First year ICD-10-CM implemented into the HIPAA code set)
  • FY 2017 - No Change, effective from 10/1/2016 through 9/30/2017
  • FY 2018 - No Change, effective from 10/1/2017 through 9/30/2018
  • FY 2019 - No Change, effective from 10/1/2018 through 9/30/2019
  • FY 2020 - No Change, effective from 10/1/2019 through 9/30/2020

Information for Patients


Women's Health Checkup

Regular health exams and tests can help find problems before they start. They also can help find problems early, when your chances for treatment are better. As a woman, you need some special exams and screenings. During your checkup, your health care provider will usually do:

  • A pelvic exam - an exam to check if internal female organs are normal by feeling their shape and size.
  • A Pap test - a test to check for cancer of the cervix, the opening to a woman's uterus. Cells from the cervix are examined under a microscope.
  • A clinical breast exam - to check for breast cancer by feeling and looking at your breasts.

Your health care provider may also recommend other tests, including a mammogram or a test for HPV.


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