# ICD-10 Coding Question-I am a little



## natwilson (Oct 1, 2015)

I am a little confused on ICD-10 code Z00.00 and Z00.01.  I don't really understand the abnormal findings indicated in Z00.01.  If a patient is seen and complains of "heartburn" but has not been diagnosed with GERD until this visit then should the provider use Z00.00 or Z00.01?  I just don't understand if the abnormal findings are things that were not previously diagnosed but the patient complains about and the provider diagnoses in the appointment  or if they are things that the provider has to order additional testing to confirm the diagnosis or something else.  Any help with this would be greatly appreciated.


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## mitchellde (Oct 1, 2015)

If the patient presents with a complaint of heartburn, you cannot code a well visit.  The excludes 1 note states."excludes 1encounter for signs and symptoms, - code to the signs and symptoms.
An abnormal finding is the provider documenting a abnormality discovered on exam of an asymptomatic patient that presented for a routine wellness visit.


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## beesknees (Oct 1, 2015)

the way i understand it only if its detected at the visit it would be w/abnormal findings.  What i'm questioning is do we link the abnormal finding along with the well visit? or just leave it as a floating diagnosis on the claim.


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## mitchellde (Oct 1, 2015)

You link it together


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## vincil (Oct 1, 2015)

*Z00.00*

In the past, if I had a patient come in just for a blood draw for labs that we send out, it was coded V72.60 for Lab exam NOS. The crosswalk shows this in I10 as Z00.00, but a routine medical exam (V70.0) is also listed as Z00.00 or Z00.01 with abnormal findings. 
Is this correct? So if I have an adult come in for a routine medical exam with or without labs, it would be Z00.00 (or 01) or if someone came in for labs alone that would also be Z00.00 (or 01)


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## mitchellde (Oct 1, 2015)

I think you need to code the reason for the labs, use screening for screening labs and Z51.81 for labs that are for certain medications the patient has been taking.


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## jdvapeds (Oct 1, 2015)

Sort of the same question except for Pediatrics: I have heard conflicting opinions about when to use Z00.129 vs. Z00.121.  Almost every ped patient as you know has something else going on at a well visit, whether it’s diaper rash, eczema, cold, cough, ears, asthma etc.   Do we code them all as abnormality?  (and then obviously use the appropriate codes in addition) or is it only for abnormality related to the well visit or "discovered" at the well visit.  What if we already know they have a cardiac murmur vs. newly diagnosed.


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## mitchellde (Oct 1, 2015)

You really need to read all the information in the code book.  Z00 category description states encounter for general exam without complaint, suspected, or reported diagnosis.
If the child is in obvious distress, this is abv complaint and you cannot use the the Z00 code, if the provider suspects a problem based on the patient presentation, then that is a suspected diagnosis and you cannot use a Z00 and if the patient has a pre existing condition that requires treatment then this is a reported diagnosis and you cannot report the Z00.  The Z00 codes are for well visits for asymptomatic patients.  A problem discovered in an otherwise well appearing patient is an abnormal finding


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## vincil (Oct 1, 2015)

That makes sense. Thanks Debra!


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