Question: When you are asked to see an infant for suspected shaken baby syndrome and there are no findings, what diagnosis code should you report?

Answer: Z01.00 Routine exam with normal findings. Approximate synonyms:

• Emmetropia
• Encounter for exam of eyes and vision- normal findings
• Examination of eyes and vision- normal findings done
• Examination of eyes and vision- normal findings done (situation)
• Eye and vision exam normal • Eye and vision exam, routine, normal findings
• Eye exam, problem focused w normal findings
• Eye exam, problem focused with normal findings
• Large physiologic cupping of optic disc
• Normal vision
• Optic nerve cupping
• Physiologic optic disc cupping, large
• Problem focused eye exam with normal findings
• Problem focused eye exam with normal findings (procedure)
• Routine child vision test
• Routine child vision testing
• Routine child vision testing done
• Routine child vision testing done (situation)
• Visual acuity screening
• Visual acuity screening done
• Visual acuity screening done (situation)

For more on diagnosing shaken-baby syndrome, see also the 2016 Focal Points issue on Ocular Manifestations of Child Abuse and the Academy’s clinical statement, Abusive Head Trauma, Shaken Baby Syndrome.