# CPE's with/without abnormal findings



## susansipe (Oct 9, 2015)

IGNORE THIS>>>>
we should have searched first before posting....
found some answers
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Hey all.  Family Medicine Group here.
We are trying to define the abnormal findings at a CPE use.

One of us believes it is used when you find a new problem at that visit.
Two of us believe it is related to results of Labs for PE that you did prior to the PE.

Please weigh in as we do LOTS of CPE's daily here.

Thanks!
Sue


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## mitchellde (Oct 9, 2015)

An abnormal finding is any abnormality discovered by the provider in a patient that presents asymptomatic.  Even if they have chronic conditions, as long as the payient has no complaints.  Abnormal findings might be a new problem or it could be an abnormality with one of the chronic problems that the patient professed they were having no problems with.


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## knjngn (Oct 13, 2015)

*With or Without Abnormal findings*

I too am struggling with when to use Z00.00 vs Z00.01.
My docs want to use 'without abnomral findings' even if the patient has chronic conditions that are being managed and only use 'with abnormal findings' if there is a new or acute problem that is addressed at the visit and I am torn over which is correct.


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## mitchellde (Oct 13, 2015)

If the new acute problem us something the payient presents with as a symptomatic complaint or a condition where the provider immediately suspects something then you cannot call it an annual.  The exclude 1 note states excludes1 signs and symptoms- code to the signs and symptoms.  And the category states without complaint, suspected, or reported diagnosis,
Without abnormal findings is for the annual preventive with no complaints, even though chronic issues exist, but no abnormalities, management only.
With abnormal findings is this same patient that presents asymptomatic but the provider discovers something indicating not as well as the patient presents.


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