Z01.411

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

Billable / specificPOA exempt

Z01.411 is a billable, specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes in FY2027.

Inclusion terms

Includes (from Z01)

  • routine examination of specific system
  • Note: Z codes represent reasons for encounters. A corresponding procedure code must accompany a Z code if a procedure is performed. Categories Z00-Z99 are provided for occasions when circumstances other than a disease, injury or external cause classifiable to categories A00-Y89 are recorded as 'diagnoses' or 'problems'. This can arise in two main ways:
  • Note: (a) When a person who may or may not be sick encounters the health services for some specific purpose, such as to receive limited care or service for a current condition, to donate an organ or tissue, to receive prophylactic vaccination (immunization), or to discuss a problem which is in itself not a disease or injury.
  • Note: (b) When some circumstance or problem is present which influences the person's health status but is not in itself a current illness or injury.
  • Note: Nonspecific abnormal findings disclosed at the time of these examinations are classified to categories R70-R94.
  • Note: Codes from category Z01 represent the reason for the encounter. A separate procedure code is required to identify any examinations or procedures performed

Excludes1

Not coded here — never report together with this code.

  • gynecologic examination status-post hysterectomy for malignant condition (Z08) (from Z01.41)
  • screening cervical pap smear not a part of a routine gynecological examination (Z12.4) (from Z01.41)
  • encounter for examination for administrative purposes (Z02.-) (from Z01)
  • encounter for examination for suspected conditions, proven not to exist (Z03.-) (from Z01)
  • encounter for laboratory, radiologic and imaging examinations for sign(s) and symptom(s) - code to the sign(s) or symptom(s) (from Z01)

Excludes2

Not included here — may be reported together when both conditions exist.

  • pregnancy examination or test (Z32.0-) (from Z01.4)
  • routine examination for contraceptive maintenance (Z30.4-) (from Z01.4)
  • examinations related to pregnancy and reproduction (Z30-Z36, Z39.-) (from Z01)
  • encounter for laboratory and radiologic examinations as a component of general medical examinations (Z00.0-) (from Z01)
  • screening examinations (Z11-Z13) (from Z01)

Use additional code

Add a code to identify the following, if applicable.

  • code to identify abnormal findings
  • code: (from Z01.41)
  • for screening for human papillomavirus, if applicable, (Z11.51) (from Z01.41)
  • for screening vaginal pap smear, if applicable (Z12.72) (from Z01.41)
  • to identify acquired absence of uterus, if applicable (Z90.71-) (from Z01.41)

Also known as

  • Examination, annual, gynecological, with abnormal findings
  • Examination, cervical Papanicolaou smear, as part of routine gynecological examination, with abnormal findings
  • Examination, gynecological, with abnormal findings
  • Examination, pelvic, with abnormal findings
  • Gynecological examination, with abnormal findings
  • Papanicolaou smear, cervix, as part of routine gynecological examination, with abnormal findings
  • Papanicolaou smear, cervix, routine, with abnormal findings
  • Pelvic, examination, with abnormal findings

Parent code

  • Z01.41Encounter for routine gynecological examinationHeader

Related codes

  • Z01.419Encounter for gynecological examination (general) (routine) without abnormal findingsBillable

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