Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings

Billable ICD-10-CM code, FY2026. Exempt from present-on-admission (POA) reporting.

Use additional code

• code to identify abnormal findings

Applies from Z01 Encounter for other special examination without complaint, suspected or reported diagnosis

Includes

• routine examination of specific system

Excludes1 (never code together)

• encounter for examination for administrative purposes (Z02.-)
• encounter for examination for suspected conditions, proven not to exist (Z03.-)
• encounter for laboratory, radiologic and imaging examinations for sign(s) and symptom(s) - code to the sign(s) or symptom(s)

Excludes2 (not included here)

• encounter for laboratory and radiologic examinations as a component of general medical examinations (Z00.0-)
• screening examinations (Z11-Z13)

Notes

• Codes from category Z01 represent the reason for the encounter. A separate procedure code is required to identify any examinations or procedures performed

Applies from Z01.4 Encounter for gynecological examination

Excludes2 (not included here)

• pregnancy examination or test (Z32.0-)
• routine examination for contraceptive maintenance (Z30.4-)

Applies from Z01.41 Encounter for routine gynecological examination

Applicable to

• Encounter for general gynecological examination with or without cervical smear
• Encounter for gynecological examination (general) (routine) NOS
• Encounter for pelvic examination (annual) (periodic)

Excludes1 (never code together)

• gynecologic examination status-post hysterectomy for malignant condition (Z08)
• screening cervical pap smear not a part of a routine gynecological examination (Z12.4)

Use additional code

• 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-)

MS-DRG index

Defines the logic of DRG(s) 951 in MDC 23.

Approximate ICD-9-CM (GEMs)

• V72.31 Routine gynecological examination (approximate)

Code annotations containing back-references to Z01.411

Back-references to Z01.4

• Type 1 Excludes: Z12.4 Encounter for screening for malignant neoplasm of cervix ("when screening is part of general gynecological examination (Z01.4-)")

Back-references to Z01

• Type 1 Excludes: Z02.7 Encounter for issue of medical certificate ("encounter for general medical examination (Z00-Z01, Z02.0-Z02.6, Z02.8-Z02.9)")
• Type 2 Excludes: Z71.84 Encounter for health counseling related to travel ("encounter for other special examination without complaint, suspected or reported diagnosis (Z01.-)")

Diagnosis Index entries for Z01.411

• Examination (for) (following) (general) (of) (routine) › annual (adult) (periodic) (physical) › gynecological › with abnormal findings
• Examination (for) (following) (general) (of) (routine) › cervical Papanicolaou smear › as part of routine gynecological examination › with abnormal findings
• Examination (for) (following) (general) (of) (routine) › gynecological › with abnormal findings
• Examination (for) (following) (general) (of) (routine) › pelvic (annual) (periodic) › with abnormal findings
• Gynecological examination (periodic) (routine) › with abnormal findings
• Papanicolaou smear, cervix › as part of routine gynecological examination › with abnormal findings
• Papanicolaou smear, cervix › routine › with abnormal findings
• Pelvic › examination (periodic) (routine) › with abnormal findings

Nearby codes

• Z01.3 Encounter for examination of blood pressure
• Z01.30 Encounter for examination of blood pressure without abnormal findings
• Z01.31 Encounter for examination of blood pressure with abnormal findings
• Z01.4 Encounter for gynecological examination
• Z01.41 Encounter for routine gynecological examination
• Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings (this code)
• Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings
• Z01.42 Encounter for cervical smear to confirm findings of recent normal smear following initial abnormal smear
• Z01.8 Encounter for other specified special examinations
• Z01.81 Encounter for preprocedural examinations
• Z01.810 Encounter for preprocedural cardiovascular examination