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

Coding notes

From the ICD-10-CM FY2027 (effective October 1, 2026) tabular list. Notes on a parent code or category apply here too.

Includes

• routine examination of specific system

Note

• Codes from category Z01 represent the reason for the encounter. A separate procedure code is required to identify any examinations or procedures performed
• Nonspecific abnormal findings disclosed at the time of these examinations are classified to categories R70-R94.

Excludes1

Not coded together with this code. The exception is when the two conditions are unrelated to each other.

• gynecologic examination status-post hysterectomy for malignant condition (Z08)
• screening cervical pap smear not a part of a routine gynecological examination (Z12.4)
• 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 part of this code, but both can be coded when both are documented.

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

Use additional code

Add a second code for the following, when documented.

• code to identify abnormal findings
• 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-)