General Surgery Coding Alert

Question: A patient presented in the surgeon’s office for an evaluation of a suspected hernia that might require surgery. Following a thorough exam, the surgeon determined that the patient did not have a hernia. Should we use Z00.00 as the diagnosis for the surgeon’s E/M service, or should we report a hernia code?

Virginia Subscriber

Answer: No, you should not list Z00.00 (Encounter for general adult medical examination without abnormal findings) as the diagnosis for this encounter. You should reserve that code for cases involving an asymptomatic patient, with no specific complaint or problem, presenting for a routine exam.

Nor should you report a hernia diagnosis, such as K40.90 (Unilateral inguinal hernia, without obstruction or gangrene, not specified as recurrent), because ICD-10-CM guideline IV.H instructs you not to code “diagnoses documented as ‘probable,’ … ‘rule out,’ … or other similar terms indicating uncertainty.”

You should report the diagnosis code based on the presenting signs or symptoms that made the patient suspect a hernia. You don’t state those signs or symptoms in your question, and if the documentation states only that the patient thought they might have a hernia, you can report Z71.1 (Person with feared health complaint in whom no diagnosis is made) for the case.