MAR 04, 2016
Appropriate Diagnosis When No Ophthalmic Findings
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.