Examine This Encounter Lacking a Diagnosis
Question: Our pediatrician saw a 2-year-old whose father said they had been acting like they didn’t feel well but he couldn’t find anything wrong. After examining the patient, the pediatrician also found nothing wrong and therefore was unable to record a diagnosis or any signs or symptoms. How should I report this? I was thinking a Z code would be appropriate, but I’m not sure. Iowa Subscriber Answer: You are correct, a Z code would be appropriate in this case. You can use either Z03.89 (Encounter for observation for other suspected diseases and conditions ruled out) or Z71.1 (Person with feared health complaint in whom no diagnosis is made). Reporting Z03.89 is most likely the best option in this scenario. Here’s why: Codes from the Z03 category are for situations “when a person without a diagnosis is suspected of having an abnormal condition, without signs or symptoms, which requires study, but after examination and observation, is ruled out,” according to ICD-10-CM guidelines under the category. In other words, you can report these codes when the pediatrician suspects the patient might have a condition that requires treatment but then rules out the condition after examination. If you look further down to the Excludes1 note, you’ll see mention of Z71.1, which is a clue that these two codes are not interchangeable. Under Z71.1, ICD-10-CM includes “worried well” encounters, which is a term for when a patient or guardian presents with fear of illness but the child demonstrates no signs of an actual illness. The examination in these situations normally resolves with reassuring the patient or caregiver and essentially reducing their anxiety. Lindsey Bush, BA, MA, CPC, Production Editor, AAPC
