Wiki Normal v Abnormal

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danadove

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Patient presents for a routine medical exam and it has been previously documented the patient has HTN and the provider refills the patient's HTN meds - should this be coded as normal since the HTN was previously diagnosed and the provider is not addressing, but merely providing refills?

What if the provider did not provide refills but addresses the condition in the documentation as stable - would this be considered "with abnormal" findings?

Has anyone found any clear, definitive information on this topic?

Thanks in advance!

Dana
 
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So are you asking is it still a preventive em? or did they do labs and are you wondering how those would be coded as preventive, or as HTN?
 
I'm wondering when to use the Z00.01 with abnormal findings.

If the provider does a routine physical and the patient has established HTN, is it still considered with normal findings since the HTN was previously diagnosed?
 
Normal Vs Abnormal

This would most definitely be coded as Z01.419 , Routine Exam. What will define the exam as normal vs abnormal is the "findings" at the time of the visit. If the patient has no complaints at the time of the exam, it is normal. If the patient presents with a complaint that is addressed, it is abnormal findings and coded with the appropriate dx code Z01.411 and appropriate dx code addressing the findings.

Cindy Stout
 
I understand with icd 10 codes Z00 that excludes sign or symptoms, does it include that you can not bill an extra E&M if you bill with dx codes Z00 codes. For example can you bill a follow up ADHD medication follow up visit with the well code or is it considered a part of the well visit
 
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