Pediatric Coding Alert

Question: When is it appropriate to code a routine child health exam "with abnormal findings?" For example, if our provider examines a patient with a pre-existing condition, can we document "with abnormal findings?" Or does the condition have to be discovered at the time of the exam?

Missouri Subscriber

Answer: Choosing between Z00.129 (Encounter for routine child health examination without abnormal findings) and Z00.121 (Encounter for routine child health examination with abnormal findings) is actually more complex than it seems. But ICD-10-CM guidelines for Section I.C.21.13 contain one key sentence that should guide your decision making when coding this encounter: "Code assignment depends on the information that is known at the time the encounter is being coded."

As an example, suppose your pediatrician detects a newly identified condition in a patient during the routine exam. If the pediatrician provides a diagnosis at the time of the encounter, you would code Z00.121.

However, if the condition requires a test or further investigation before the pediatrician can offer a definitive diagnosis, you would follow the guidelines and report Z00.129. Again, per ICD-10-CM guidelines, "if ... the encounter is being coded before test results are back, it is acceptable to assign the code for 'without abnormal findings.'" In other words, if there is no diagnosis made at the time of the encounter, and you cannot definitively classify the exam findings as abnormal, you would be correct in reporting "without abnormal findings," or Z00.129, at this point.

Something similar is also true for preexisting conditions. You would code Z00.129 if there is no change in that condition, if, as the guidelines stipulate, "the examination is for administrative purposes and not focused on any particular condition." In other words, the encounter has to be for a routine exam, and not one that is problem-focused, even though the purpose of the preventive visit is to review all chronic issues.

But, the guidelines go on to note, you could report Z00.121 for a patient with a preexisting condition if the provider discovers "a change in severity of a chronic condition (such as uncontrolled hypertension, or an acute exacerbation of chronic obstructive pulmonary disease) during a routine physical examination." You could also report Z00.121 if your provider is changing the patient's medications even though the chronic condition is stable.

Coding alert: If you do decide to document the encounter with Z00.121, make sure you follow ICD-10-CM guidelines and assign "additional code(s) ... to identify the specific abnormal finding(s)."