Need some assistance, in correct DX for G0438. Been in a few webinars and there is some contradiction on when to use DX Z00.01 and consider an abnormal finding. Some told us that you cannot use Z00.01 if no labs ordered to detect the abnormal finding.
"An abnormal finding refers to something new, which the physician discovered during the visit. For the purpose of assigning codes from this category, an “abnormal finding” is a newly discovered condition, or a known/chronic condition that has increased in severity, (e.g., uncontrolled, and/or acutely exacerbated)."
Example: The patient has hypertension, which has been stable in the past, but upon examination today it was discovered that the patient’s blood pressure was elevated, and no longer controlled. No labs ordered.
Shouldn't this be coded at Z00.01 with chronic condition(s) ???
"An abnormal finding refers to something new, which the physician discovered during the visit. For the purpose of assigning codes from this category, an “abnormal finding” is a newly discovered condition, or a known/chronic condition that has increased in severity, (e.g., uncontrolled, and/or acutely exacerbated)."
Example: The patient has hypertension, which has been stable in the past, but upon examination today it was discovered that the patient’s blood pressure was elevated, and no longer controlled. No labs ordered.
Shouldn't this be coded at Z00.01 with chronic condition(s) ???