Here are some examples of abnormal findings that could be coded during a routine preventive exam:
- Lump or mass found on physical exam
- Abnormal lab or test result (e.g. high blood pressure, abnormal pap smear)
- Enlarged lymph nodes
- Heart murmur
- Skin lesion or rash
- Joint swelling or pain
The key is that it was an unexpected or unintended finding, not the reason for the exam. Routine screening exams are not coded if they are normal. Only code an abnormal finding if it is documented.