Encounters for routine child health examinations with and without abnormal findings

[jbailey]

The topic of how and when to code with abnormal findings keep resurfacing in my office. My understanding is if a child had a previous dx of ADHD, this would be coded as child health examination Z00.12. If however you had a child who presents with behavioral concerns (new) and further follow up is needed, Z00.121.

If a child has an ear infection at the time of the exam, would you code this as an abnormal finding? Any clarification to this would be helpful.

Thank you,

Jeannine T. Bailey CMA, CPC, ACMPE
Londonderry Pediatrics, PA

 

[mitchellde]

The category description is a pRt of each code description.
Z00 reads encounter for general exam without complaint, suspected, or reported diagnosis.
So a previously diagnosed condition is not an abnormal finding, a mother that expresses behavioral concerns is not an abnormal finding and a child that presents with symptoms that the providers then states is an ear infection is not an abnormal finding. Visits for these conditions are not well child visits. If the child has a pre existing problem like ADHD and the well child visit includes reordibg meds, then that is a well child visit without abnormal findings. If the child is well and the mother expresses concerns regarding behavior then a visit should be scheduled to address hat or the well child visit should be rescheduled. If the child presents symptomatic, then the well child visit needs to be rescheduled.