Wiki Z01.149 vs Z01.141

[jlwhalley]

Looking for clarification on the posting of annual codes with no abnormal and abnormal findings. I know that an "abnormal finding" is a newly discovered condition, or a known/chronic condition that his uncontrolled or exacerbated. What I'm specifically looking for is when to use the Z01.141 code... Would abnormal be considered only if the condition is related to the reproductive/gynecological system? Or does this code include other abnormal health problems such as uncontrolled HTN? For example, if a patient has an annual exam with a pap smear (with no abnormal findings related to that system) but discusses uncontrolled HTN, would that be the abnormal code still?
On that note, would obesity be considered an abnormal finding for either Z00.00 OR Z01.149? I am finding differing answers on whether obesity constitutes an abnormal annual code, and some of my coworkers and I are coming up with contradicting answers and would appreciate some clarification to settle this!

Thanks in advance!

 

[Missdeehamp]

My understanding is that the "abnormal findings" designation is not limited to findings within the body system being examined.

For example:
* Z00.01 = Encounter for general adult medical examination with abnormal findings
* Z01.411 = Encounter for gynecological examination (general) (routine) with abnormal findings
* Z01.419 = Encounter for gynecological examination (general) (routine) without abnormal findings

The ICD-10-CM guidelines generally support reporting the "with abnormal findings" code when a significant abnormal finding is identified and documented during the encounter, with an additional diagnosis code reported to identify the specific condition.

In your example, if the patient presents for an annual gynecological exam and the provider documents uncontrolled hypertension that is evaluated and addressed during the visit, I would lean toward Z01.411 (with abnormal findings) along with the appropriate hypertension diagnosis code. The abnormal finding does not necessarily have to be a gynecological condition.
The obesity question tends to generate more debate. In my experience, obesity by itself is not automatically considered an abnormal finding simply because it appears on the problem list. However, if the provider documents obesity as an active condition that is assessed, monitored, counseled on, or impacts medical decision-making during the preventive visit, many coders would support using the "with abnormal findings" code along with the obesity diagnosis.

The distinction I usually apply is:
* Stable historical condition noted but not evaluated = generally does not drive the abnormal finding code.
* Condition that is evaluated, monitored, addressed, treated, uncontrolled, exacerbated, or otherwise clinically relevant to the encounter = more support for the abnormal finding code.

I would be interested to hear how others interpret obesity specifically, as that seems to be the area where coding guidance is applied most inconsistently.

Dee Daniels
Founder | Elevare Management Solutions
Revenue Cycle Management Consultant
www.elevaremgmts.com