Z00.01: Help understanding!

kpeterson15

Networker
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General question: Say someone comes in for a yearly visit and the patient as coexisting conditions say such as hypertension and diabetes. During this annual visit, the provider checks those conditions and they are stable. Would you code the annual visit as Z00.01(with abnormal findings) or Z00.00(without abnormal findings) and then code I10 and E11.9 in addition to the Z code since they were stable chronic conditions and were looked at during the encounter?

Thanks!
 

thomas7331

True Blue
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You can find the answer to this in the ICD-10 guidelines under Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services. In paragraph P, it states that an "An examination with abnormal findings refers to a condition/diagnosis that is newly identified or a change in severity of a chronic condition (such as uncontrolled hypertension, or an acute exacerbation of chronic obstructive pulmonary disease) during a routine physical examination."

Based on this, I would not code Z00.01 for stable chronic conditions mentioned in the documentation unless the provider has identified some change that condition, or some other new problem, during the course of the exam.
 

kpeterson15

Networker
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You can find the answer to this in the ICD-10 guidelines under Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services. In paragraph P, it states that an "An examination with abnormal findings refers to a condition/diagnosis that is newly identified or a change in severity of a chronic condition (such as uncontrolled hypertension, or an acute exacerbation of chronic obstructive pulmonary disease) during a routine physical examination."

Based on this, I would not code Z00.01 for stable chronic conditions mentioned in the documentation unless the provider has identified some change that condition, or some other new problem, during the course of the exam.
Thank you! If they are stable, can you code them with Z00.00 showing they were addressed during the encounter and they still have those conditions?
Thanks!
 
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