Person consulting for explanation of exam or test findings

This code identifies encounters where a patient is seeking clarification or interpretation of results from previously performed diagnostic tests or examinations. The patient is not presenting for a new problem or follow-up of an existing condition, but specifically to understand findings already obtained.

Apply this code when a patient schedules an appointment solely to discuss the results of a recent MRI, blood test, biopsy, or other diagnostic procedure. This is appropriate when the provider is explaining the implications of the findings, whether normal or abnormal, and no further diagnostic workup or treatment plan is initiated during this specific visit.

• Do not use if the patient is presenting for follow-up of an established condition where test results are reviewed as part of ongoing management.
• Ensure documentation clearly states the purpose of the visit is for explanation of findings.
• Consider a secondary code if a new diagnosis is made or treatment is initiated during the same encounter.