From the Official ICD-10 Rule book

P. Encounters for general medical examinations with abnormal findings
The subcategories for encounters for general medical examinations, Z00.0-, provide codes for with and without abnormal findings. Should a general medical examination result in an abnormal finding, the code for general medical examination with
ICD-10-CM Official Guidelines for Coding and Reporting
2014

Page 105 of 117

abnormal finding should be assigned as the first-listed diagnosis. A secondary code for the abnormal finding should also be coded. 


For example: patient is referred to me, the urologist, with an elevated PSA.