Z01.021 ICD-10-CM Code: Encounter for examination of eyes and vision following failed vision screening with abnormal findings

Coding instructions

Official Tabular Instructional Notes: the inclusion, exclusion and sequencing notes published for Z01.021 in the official ICD-10-CM tabular list, quoted as published.

Notes without a marker are published on Z01.021 itself; “inherited from” names the category or block whose note applies here.

Coder workflow for Z01.021

MedCoder structured workflow — derived from this code’s own official record

Before you code Z01.021

1. Z01.021’s title joins a condition with an associated condition or complication. Confirm each component is documented. Where the classification presumes the link through the “with” convention, only a provider statement that the conditions are unrelated defeats it. A combination code is assigned only when it fully identifies the documented conditions; a required second code for the stage, type or manifestation is still reported when the notes ask for it (Guidelines I.B.9, I.A.15).

   Guide: Combination codes →

2. Confirm the reason for the encounter this Z code records: an examination or encounter with no complaint or diagnosis. Check whether the code may be reported as first-listed or principal — some Z codes are limited to one position — and do not report a history or status code for a condition documented as current. Z code categories and their reporting positions (Guidelines I.C.21.c, I.C.21.c.15).

   Guide: Z codes as principal or first-listed diagnosis →

3. Check the Excludes1 note: if the documentation supports a condition named there, do not simply proceed with Z01.021. Excludes1 conditions are not reported together with this code unless the record shows they are unrelated (Guidelines I.A.12.a).

   See the official tabular notes

Choose the right path

1. Does the documentation support a condition named in Z01.021’s Excludes1 note?
   Yes → Do not simply proceed: review the excluded code. Both are reported only when the record shows the two conditions are unrelated.
   No → Continue.

   ReviewZ01.01, Z01.00, Z02.4, Z02, Z03

Consider Z01.021. Then work the Use Additional Code note, and confirm the code is valid for the date of service in the Verify section.

Documentation check

The provider’s diagnostic statement

Codes are assigned from the provider’s documented diagnosis, not from clinical criteria, test values or a medication list (Guidelines I.A.19).

The associated condition or complication

Whether the associated condition the title names is documented; the “with” convention presumes some links, and a provider statement that the conditions are unrelated defeats it (Guidelines I.A.15).

The conditions the Use Additional Code note names

Reported with this code when documented; a conditional instruction (“if applicable”, “if known”) applies only when the record supports it.

The reason for the encounter

Whether the code records the encounter’s purpose, a status, or a history — and whether it may be first-listed (Guidelines I.C.21.c).

Official instructions as workflow

• Excludes1 — check before selecting Z01.021(6 notes)

  Coding workflow: If the documentation supports a condition named in this note, do not simply proceed with Z01.021: the two are not reported together. The one exception is when the record shows the two conditions are unrelated to each other.

  CompareZ01.01, Z01.00, Z02.4, Z02, Z03

  See the official tabular notes · Guidelines I.A.12.a

• Excludes2 — not part of Z01.021(3 notes)

  Coding workflow: The conditions named in this note are not included in Z01.021. When the record documents both, both may be reported; the note is a boundary, not a prohibition.

  CompareZ00.0, Z39

  See the official tabular notes · Guidelines I.A.12.b

• Use Additional Code — after identifying Z01.021(1 note)

  Coding workflow: Check whether the documentation supports the additional code(s) the note names, and report them with Z01.021 when it does. Where the instruction is conditional (“if applicable”, “if known”), it applies only when the record documents the condition.

  See the official tabular notes · Guidelines I.A.13

Coding decision scenarios

Pattern scenarios for this code’s structure — decision rules, not clinical cases

Every row is derived from this code’s own record — its title, tabular notes, 7th-character family and same-category siblings — with fixed MedCoder wording; nothing is inferred about a patient. The official notes and guideline text are in the sections each row links to, and they control.

Indexed Clinical Terms (7)

Official source data — entries quoted as published, in the Index’s own lookup phrasing

Clinical term phrases from the official ICD-10-CM Index to Diseases and Injuries that map to this code. These are alphabetic-index entries shown as the Index writes them — lookup phrasing, not necessarily the wording of a final diagnosis.

• Admission (for), examination at health care facility (adult), eye, following failed vision screening, with abnormal findings
• Admission (for), examination at health care facility (adult), vision, following failed vision screening, with abnormal findings
• Admission (for), vision examination, following failed vision screening, with abnormal findings
• Examination (for) (following) (general) (of) (routine), eye, following failed vision screening, with abnormal findings
• Examination (for) (following) (general) (of) (routine), vision, following failed vision screening, with abnormal findings
• Test, tests, testing (for), vision, following failed vision screening, with abnormal findings
• Vision, visual, examination, following failed vision screening, with abnormal findings

Official Coding Guidelines

Official source data — quoted verbatim from the CMS/NCHS Official Guidelines

Official source data — quoted verbatim from the CMS/NCHS Official Guidelines

Verbatim excerpts from the ICD-10-CM Official Guidelines for Coding and Reporting (CMS/NCHS) that govern this code.

Don’t confuse Z01.021 with…

MedCoder analysis — pairs from this code’s official notes, distinctions written by MedCoder

The codes most likely to be picked instead of Z01.021 — named in its own official notes, or sharing its laterality or encounter family — with what separates them and which documentation moves the case. Each links to the full comparison.

• Z01.01— Excludes1 conflict (Conflict)

  Not coded here — these two are mutually exclusive.

  Not reported together with this code, except where the two conditions are documented as unrelated.

  What moves you there: Documentation of encounter for examination of eyes and vision with abnormal findings moves the case to Z01.01; the two are not reported together unless documented as unrelated.

  Full comparison: Z01.021 vs Z01.01 →

• Z01.00— Excludes1 conflict (Conflict)

  Not coded here — these two are mutually exclusive.

  Not reported together with this code, except where the two conditions are documented as unrelated.

  What moves you there: Documentation of encounter for examination of eyes and vision without abnormal findings moves the case to Z01.00; the two are not reported together unless documented as unrelated.

  Full comparison: Z01.021 vs Z01.00 →

• Z02.4— Excludes1 conflict (Conflict)

  Not coded here — these two are mutually exclusive.

  Not reported together with this code, except where the two conditions are documented as unrelated.

  What moves you there: Documentation of examination for driving license moves the case to Z02.4; the two are not reported together unless documented as unrelated.

  Full comparison: Z01.021 vs Z02.4 →

• Z02— Excludes1 conflict (Conflict)

  Not coded here — these two are mutually exclusive.

  Not reported together with this code, except where the two conditions are documented as unrelated.

  What moves you there: Documentation of examination for driving license moves the case to Z02; the two are not reported together unless documented as unrelated.

  Full comparison: Z01.021 vs Z02 →

• Z03— Excludes1 conflict (Conflict)

  Not coded here — these two are mutually exclusive.

  Not reported together with this code, except where the two conditions are documented as unrelated.

  What moves you there: Documentation of encounter for examination for suspected conditions, proven not to exist moves the case to Z03; the two are not reported together unless documented as unrelated.

  Full comparison: Z01.021 vs Z03 →

• Z00.0— Excludes2 relationship (Informational)

  Distinct conditions — both may be reported.

  A distinct condition — both may be reported when both are documented.

  What moves you there: Documentation of encounter for laboratory and radiologic examinations as a component of general medical examinations adds Z00.0; it is not part of this code and both may be reported when both are documented.

  Full comparison: Z01.021 vs Z00.0 →

Relationships are read from this code's own official notes, its laterality siblings and its encounter family; the wording of each distinction is MedCoder editorial, and the documentation named in each “what moves you there” line is the official note phrase or sibling title itself. Source: CMS ICD-10-CM tabular instructional notes; ICD-10-CM Official Guidelines, Section I.A.12.a.

Decision Points

The directives on this code's own record, as a pre-claim checklist.

1. 1 Use Additional Code instruction — report the named additional code(s) when the documentation supports them. See the Use Additional Code notes
2. 6 Excludes1 entries — codes named there are generally not reported together with this code (Guidelines I.A.12.a). See the Excludes1 notes
3. 3 Excludes2 entries — those conditions are not part of this code and may be reported additionally when documented. See the Excludes2 notes

Checklist rows are derived from this code's own official directives; the wording of each check is MedCoder editorial. The official notes themselves are in the sections each row links to.

Verify Before Coding

• No Medicare Code Editor or MS-DRG Definitions Manual restrictions apply to this code.

From the code registry, the Medicare Code Editor, and the MS-DRG Definitions Manual. Check it against a full claim in Claim Check.

Relationships & Classification

MedCoder structured relationships — computed from published CMS and AHRQ datasets

Other codes that name Z01.021 or its code family, from the CMS ICD-10-CM tabular instructional notes. Tabular-note edges are stored at the code family level that carries each note.

Referenced by 1 Excludes1 note: Z02.7 — Encounter for issue of medical certificate (via Z01.-).

These codes’ tabular lists mark this diagnosis as mutually exclusive — not reported together unless the conditions are documented as unrelated.

Referenced by 2 Excludes2 notes: Z13.5 — Encounter for screening for eye and ear disorders (via Z01.0.-), Z71.84 — Encounter for health counseling related to travel (via Z01.-).

These codes’ tabular lists name this diagnosis as distinct — both may be reported when both are documented.

MS-DRG Grouper Relationships (FY2026)

Potential MS-DRG participation — not a DRG assignment.

Not on the CMS CC/MCC list — as a secondary diagnosis this code does not change MS-DRG severity.

Named in the grouper logic of 1 MS-DRG: DRG 951 (MDC 23).

From the CMS MS-DRG Definitions Manual (Appendices B and C). Actual DRG assignment depends on the complete claim.

Clinical classification (AHRQ CCSR):FAC014 — Medical examination/evaluation (default).

Clinical Classifications Software Refined (CCSR) for ICD-10-CM Diagnoses. Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality.

Related Codes

Same clinical category (CCSR)

AHRQ's Clinical Classifications Software groups these diagnoses under the same clinical category (Medical examination/evaluation).

Z00.2 — Encounter for examination for period of rapid growth in childhood, Z00.3 — Encounter for examination for adolescent development state, Z00.5 — Encounter for examination of potential donor of organ and tissue, Z00.6 — Encounter for examination for normal comparison and control in clinical research program, Z00.70 — Encounter for examination for period of delayed growth in childhood without abnormal findings, Z00.71 — Encounter for examination for period of delayed growth in childhood with abnormal findings, Z00.8 — Encounter for other general examination, Z01.00 — Encounter for examination of eyes and vision without abnormal findings, Z01.01 — Encounter for examination of eyes and vision with abnormal findings, Z01.020 — Encounter for examination of eyes and vision following failed vision screening without abnormal findings, Z01.10 — Encounter for examination of ears and hearing without abnormal findings, Z01.110 — Encounter for hearing examination following failed hearing screening, Z01.118 — Encounter for examination of ears and hearing with other abnormal findings, Z01.12 — Encounter for hearing conservation and treatment, Z01.20 — Encounter for dental examination and cleaning without abnormal findings, Z01.21 — Encounter for dental examination and cleaning with abnormal findings, Z01.30 — Encounter for examination of blood pressure without abnormal findings, Z01.31 — Encounter for examination of blood pressure with abnormal findings, Z01.411 — Encounter for gynecological examination (general) (routine) with abnormal findings, Z01.419 — Encounter for gynecological examination (general) (routine) without abnormal findings, +15 more

Same Index main term, other category

The ICD-10-CM Index to Diseases and Injuries files this code under the main terms “Examination”, “Test, tests, testing”, “Admission”, …; these codes share that main term but sit in a different category of the Tabular List.

R76.11 — Nonspecific reaction to tuberculin skin test without active tuberculosis (Mantoux, abnormal result), Z00.00 — Encounter for general adult medical examination without abnormal findings, Z00.01 — Encounter for general adult medical examination with abnormal findings (with abnormal findings), Z00.121 — Encounter for routine child health examination with abnormal findings (child, with abnormal findings), Z00.129 — Encounter for routine child health examination without abnormal findings (child), Z00.2 — Encounter for examination for period of rapid growth in childhood (period of rapid growth in childhood), Z00.3 — Encounter for examination for adolescent development state (adolescent), Z00.5 — Encounter for examination of potential donor of organ and tissue (donor), Z00.6 — Encounter for examination for normal comparison and control in clinical research program (clinical research investigation), Z00.8 — Encounter for other general examination (psychiatric NEC), Z02.0 — Encounter for examination for admission to educational institution (medical, admission to, school), Z02.1 — Encounter for pre-employment examination (medical, pre-employment), Z02.2 — Encounter for examination for admission to residential institution (medical, admission to, old age home), Z02.3 — Encounter for examination for recruitment to armed forces (medical, admission to, armed forces), Z02.4 — Encounter for examination for driving license (medical, driving license), Z02.5 — Encounter for examination for participation in sport (physical, sports), Z02.6 — Encounter for examination for insurance purposes (medical, insurance purposes), Z02.81 — Encounter for paternity testing (medical, paternity testing), Z02.82 — Encounter for adoption services (medical, adoption), Z02.83 — Encounter for blood-alcohol and blood-drug test (blood-drug), +123 more

Contextual Map

Every relationship of Z01.021 in one view: hierarchy, official tabular instructions in both directions, clinical classification, risk adjustment, MS-DRG participation, index terms and change history — each edge carrying the CMS source it derives from.

Run Z01.021 with these 3 related codes in Claim Check

Hierarchy

• Z00-Z99 — Chapter 21: Factors Influencing Health Status and Contact with Health Services (Z00-Z99) (Z00-Z99)[Hierarchy]— CMS ICD-10-CM tabular structure · icd10cm-fy2026
• Z00-Z13 — Persons encountering health services for examinations[Hierarchy]— CMS ICD-10-CM tabular structure · icd10cm-fy2026

Referenced by Excludes1 notes

• Z02.7 — Encounter for issue of medical certificate[Excludes1](via Z01.-): “encounter for general medical examination (Z00-Z01, Z02.0-Z02.6, Z02.8-Z02.9)”— CMS ICD-10-CM tabular instructional notes · icd10cm-fy2026

Referenced by Excludes2 notes

• Z13.5 — Encounter for screening for eye and ear disorders[Excludes2](via Z01.0.-): “encounter for general vision examination (Z01.0-)”— CMS ICD-10-CM tabular instructional notes · icd10cm-fy2026
• Z71.84 — Encounter for health counseling related to travel[Excludes2](via Z01.-): “encounter for other special examination without complaint, suspected or reported diagnosis (Z01.-)”— CMS ICD-10-CM tabular instructional notes · icd10cm-fy2026

Clinical classification (CCSR)

• FAC014 — Medical examination/evaluation[CCSR]— AHRQ CCSR for ICD-10-CM Diagnoses (HCUP)

MS-DRG Grouper

• DRG 951 — OTHER FACTORS INFLUENCING HEALTH STATUS[MS-DRG]: “OTHER FACTORS INFLUENCING HEALTH STATUS (MDC 23)”— CMS MS-DRG Definitions Manual (Appendix B) · FY2026

MDC crossing

• MDC 23 — Factors Influencing Health Status and Other Contacts with Health Services[MDC crossing]: “Factors Influencing Health Status and Other Contacts with Health Services — the grouper's crossing between diagnoses and procedures: a principal diagnosis sets the MDC, and same-MDC procedures move the stay to its surgical DRGs. 1,235 same-MDC procedures group here; browse them on the MDC page.”— CMS MS-DRG Definitions Manual · FY2026

Index entries

• Admission (for), examination at health care facility (adult), eye, following failed vision screening, with abnormal findings[Index term]— CMS ICD-10-CM Index to Diseases and Injuries · icd10cm-fy2026
• Admission (for), examination at health care facility (adult), vision, following failed vision screening, with abnormal findings[Index term]— CMS ICD-10-CM Index to Diseases and Injuries · icd10cm-fy2026
• Admission (for), vision examination, following failed vision screening, with abnormal findings[Index term]— CMS ICD-10-CM Index to Diseases and Injuries · icd10cm-fy2026
• Examination (for) (following) (general) (of) (routine), eye, following failed vision screening, with abnormal findings[Index term]— CMS ICD-10-CM Index to Diseases and Injuries · icd10cm-fy2026
• Examination (for) (following) (general) (of) (routine), vision, following failed vision screening, with abnormal findings[Index term]— CMS ICD-10-CM Index to Diseases and Injuries · icd10cm-fy2026
• Test, tests, testing (for), vision, following failed vision screening, with abnormal findings[Index term]— CMS ICD-10-CM Index to Diseases and Injuries · icd10cm-fy2026
• Vision, visual, examination, following failed vision screening, with abnormal findings[Index term]— CMS ICD-10-CM Index to Diseases and Injuries · icd10cm-fy2026

Nearest codes (33)

• Z01 — Encounter for other special examination without complaint, suspected or reported diagnosis[Sibling]— CMS ICD-10-CM tabular structure · icd10cm-fy2026
• Z01.0 — Encounter for examination of eyes and vision[Sibling]— CMS ICD-10-CM tabular structure · icd10cm-fy2026
• Z01.00 — Encounter for examination of eyes and vision without abnormal findings[Sibling]— CMS ICD-10-CM tabular structure · icd10cm-fy2026
• Z01.01 — Encounter for examination of eyes and vision with abnormal findings[Sibling]— CMS ICD-10-CM tabular structure · icd10cm-fy2026
• Z01.02 — Encounter for examination of eyes and vision following failed vision screening[Sibling]— CMS ICD-10-CM tabular structure · icd10cm-fy2026
• Z01.020 — Encounter for examination of eyes and vision following failed vision screening without abnormal findings[Sibling]— CMS ICD-10-CM tabular structure · icd10cm-fy2026
• Z01.1 — Encounter for examination of ears and hearing[Sibling]— CMS ICD-10-CM tabular structure · icd10cm-fy2026
• Z01.10 — Encounter for examination of ears and hearing without abnormal findings[Sibling]— CMS ICD-10-CM tabular structure · icd10cm-fy2026
• and 25 more

Change history

• FY2020 — Added to the code set[Change history]— CMS release files (code change ledger) · icd10cm-fy2020

Sources for this page

Codes, titles, notes, index terms and mappings on this page are transcribed from the datasets below. Relationships MedCoder computed and text MedCoder wrote are labelled where they appear.

Code, title, tabular notes and index terms Official source data

CMS/CDC ICD-10-CM FY2026 tabular list, index and tables, effective October 1, 2025 Release, file and checksum · Publisher’s page

Coding guidelines Official source data

ICD-10-CM Official Guidelines for Coding and Reporting (FY2026), quoted by section Release, file and checksum · Publisher’s page

Claim edits Official source data

CMS Definitions of Medicare Code Edits — v43.1 (April 2026) Release, file and checksum · Publisher’s page

Inpatient payment groups Official source data

CMS MS-DRG Definitions Manual (incl. Appendix B diagnosis index, Appendix C CC/MCC list, Appendix E procedure index) and IPPS Final Rule tables — v43 Release, file and checksum · Publisher’s page

Change history and date-of-service validity Official source data

CMS ICD-10-CM release addenda, ingested release by release into the change ledger Release, file and checksum · Publisher’s page

Comparisons, relationships and the contextual map MedCoder structured relationship

Computed by MedCoder from the tabular notes and tables above; every derived relationship is marked as derived where it appears

Summary and FAQ answers MedCoder explanation

Written by MedCoder to explain the sources above: drafted with AI assistance, checked by a person against the release files, and labelled as MedCoder text where it appears. Not official text.

Labels on this page: Official source data · MedCoder structured relationship · MedCoder explanation. How to read the labels · All data sources and release dates

Nearest Codes in This Family

Official ICD-10-CM classifications closest to Z01.021 in its code family, with their registry titles.

• Z01.0 — Encounter for examination of eyes and vision
• Z01.00 — Encounter for examination of eyes and vision without abnormal findings
• Z01.01 — Encounter for examination of eyes and vision with abnormal findings
• Z01.02 — Encounter for examination of eyes and vision following failed vision screening
• Z01.020 — Encounter for examination of eyes and vision following failed vision screening without abnormal findings
• Z01.1 — Encounter for examination of ears and hearing
• Z01.10 — Encounter for examination of ears and hearing without abnormal findings
• Z01.11 — Encounter for examination of ears and hearing with abnormal findings
• Z01.110 — Encounter for hearing examination following failed hearing screening
• Z01.118 — Encounter for examination of ears and hearing with other abnormal findings

View all codes in the Z01 family