Coding Annual Physical with Chronic Conditions

Laureen: Q: [Annual Physical] “ICD-10 question, if a patient is in for an annual physical and has chronic conditions like diabetes mellitus or hypertension, would you use Z00.01?”

Alicia: Chandra knows this one.

Chandra: A: Z00.01 is annual preventive or adult preventive examination with abnormal findings. As we talked about earlier, abnormal findings means we found something during that exam that we didn’t already know that the patient had. Chronic conditions would be things we already knew the patient had.

The thing that I go back to with that and then determining whether we knew it ahead of time, look at some of your documentation guidelines. If you really want to think about it, I’m going to cite inpatient for a minute, but if you look at your Present on Admission Guidelines, they tell you any chronic condition that patient had before they were admitted are considered present on admission. It’s kind of the same thought, they come in and do a preventive exam, we knew they had hypertension, we knew they had diabetes, we knew they had whatever.

Even if we write them a script to refill those meds, it’s not that we found something abnormal during this exam. It’s simply that we gave them a script for their chronic conditions.

ICD 10 Coding Question — Coding Annual Physical with Chronic Conditions — VIDEO

Laureen: Very good.

Alicia: If it is a new condition, they’ll document that they’ll be doing counseling on they’re sending them to the diabetes nurse and getting counseling on nutrition that this is a new finding but…

Chandra: And then in that case, then they also have to make sure that anytime they use the code that says they did a preventive with an abnormal finding they need an additional code to identify what that abnormal finding is. That’s typically where they’re going to be saying, “Oh, we just found this abnormal lesion on the skin, we better do a biopsy” or “we found a breast lump” or “we found uterine fibroids” or “we found this heart murmur” and they’re going to be ordering additional workup, doing additional things for that in most situations.

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