Primary Care Coding Alert

Question: I am confused about when to use Z00.00 or Z00.01. If a patient has a preexisting condition that is stable, and the examination finds that that problem requires no new plan of care, do I still code Z00.01 because of the problem?

New York Subscriber

Answer: The answer to your question can be found in Section IV of the ICD-10 Official Guidelines. In part, paragraph P defines an examination with abnormal findings as one that reveals “a condition/diagnosis that is newly identified or 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.”

This means Z00.01 (Encounter for general adult medical examination with abnormal findings) is not intended for a condition that is stable. The American Hospital Association (AHA) gives the following clinical example: during an annual physical examination “a patient’s blood pressure is noted to be elevated, and the physician adjusts the antihypertensive meds for better control.” In this case, the fact that the physician discovered the patient’s blood pressure was elevated and uncontrolled during the visit means that the problem is both new and abnormal and has led to a change in the patient’s care plan, and coding Z00.01 would be correct in this case (Source: AHA ICD-10-CM Coding Clinic, Vol. 3, No. 1, 2016).

So, in cases of routine physicals where a provider has not diagnosed a new problem, found no exacerbation of an existing problem, or changed an existing care plan due to an existing condition being stable, you would use Z00.00 (Encounter for general adult medical examination without abnormal findings).