# ICD-10 Routine Exam with abnormal findings



## dmgomez (Feb 18, 2014)

We are having a group discussion on Routine Exam with abnormal findings.  A child is at the physicians office for a routine exam, during the routine exam it is discovered the child has an earache. We have reviewed Section III, Part B, page 28 in the ICD-10 coding guidelines. which states abnormal findings (laboratory, X-ray, pathologic and other diagnostic results). So we believe that according to guidelines this does not qualitfy as an abnormal findings. We would like your view on this matter.


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## mitchellde (Feb 18, 2014)

Was the patient symptomatic?  If so then for ICD-10 CM you code the symptom only.  If the patient was asymptomatic and an infection is discovered on diagnostic exam the yes I call this an abnormal finding.  It is a finding by the provider that was not suspected due to a normal healthy appearing patient.  The exam constitutes a diagnostic exam


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## dmgomez (Feb 18, 2014)

Thanks Debra!


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