Coding Medical Exams with Abnormal Findings

Q: When a patient presents to their doctor for their annual exam, sometimes there may be what is called an “abnormal finding” presented during the encounter. These are considered unexpected or undiagnosed issues for the patient. During the examination, the provider may identify an abnormal finding. When this occurs, a code from subcategory Z00.0 for general medical examinations is used with the specific ICD-10-CM code identifying general exams with abnormal findings as the primary code. This would be identified as Z00.01 as Z00.00 is defined as an Encounter for general adult medical examination without abnormal findings. The abnormal findings are reported as additional codes. According to the ICD-10-CM guidelines, “An examination with abnormal findings refers to a condition/diagnosis that is newly identified or a change in the severity of a chronic condition (such as uncontrolled hypertension, or an acute exacerbation of chronic obstructive pulmonary disease) during a routine physician examination.”