Urology Coding Alert

Question: A patient came to our office with a suspected inguinal hernia, but no symptoms. There used to be an ICD-9 code for a normal exam when a complaint was not demonstrated, but I can’t find anything like that in ICD-10. What should we report?

New Jersey Subscriber

Answer: ICD-10 code Z00.00 (Encounter for general adult medical examination without abnormal findings) is the diagnostic code for an encounter for an asymptomatic adult periodic examination (“an annual physical examination…”) where there is no specific problem or complaint. However, when a patient presents with a suspected problem and undergoes an examination, bill the appropriate E/M visit code and append an ICD-10 code representing the reason for the visit. In this case, that would be a suspected inguinal hernia (K40.90). If the suspected condition is not present or discovered, also add ICD-10 code Z71.1 (Person with feared health complaint in whom no diagnosis is made) to indicate the clinical absence of the suspected problem.

Therefore, for your case, report the primary diagnosis K40.90 and the secondary diagnosis Z71.1 to clearly indicate the clinical scenario.