Adult and Child Exams
ICD-10-CM Guideline I.C.21.13) Routine and administrative examinations
The Z codes allow for the description of encounters for routine examinations, such as, a general check-up, or, examinations for administrative purposes, such as, a pre-employment physical. The codes are not to be used if the examination is for diagnosis of a suspected condition or for treatment purposes. In such cases the diagnosis code is used. During a routine exam, should a diagnosis or condition be discovered, it should be coded as an additional code. Pre-existing and chronic conditions and history codes may also be included as additional codes as long as the examination is for administrative purposes and not focused on any particular condition.
Codes for routine health exam distinguish between with & without abnormal findings. Code assignment depends on the information known at the time the encounter is being coded.
For example, if no abnormal findings were found during the examination, but the encounter is being coded before test results are back, it is acceptable to assign the code for “without abnormal findings.” When assigning a code for “with abnormal findings,” additional code(s) should be assigned to identify the specific abnormal finding(s).
The information below provides additional clarity to distinguish between “with and without abnormal condition” examination codes.
Abnormal Findings: Assign the appropriate code for with abnormal findings ( Z00.121 or Z00.01) when the examination results in:
- A newly found condition or symptom
- A change in severity of a chronic condition (for example acute exacerbation of asthma)
- A medication adjustment to better control previously diagnosed acute or chronic conditions
- A abnormal diagnostic or routine test findings
Remember when assigning a code for “with abnormal findings,” additional code(s) should be assigned to identify the specific abnormal finding(s).
Without Abnormal Findings: Assign the appropriate code for “without abnormal findings” (Z00.129 or Z00.00) when the examination results in:
- no new conditions or symptoms are found
- no abnormal test results are documented
- previously established diagnosed conditions are stable or improving on current treatment including medications
- no exacerbation or change in status of chronic conditions
Remember the guideline states if the encounter is coded before test results are back use the appropriate code for examination” without abnormal findings. “
Reference: Coding Clinic First Quarter 2016 p. 34-35