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ICD-10-CM Coding in Preventive Medicine

This is the second of a three-part series addressing coding challenges associated with preventive medicine services. 

Part 1 – When a “Problem” is Discovered During Preventive Medicine Encounter

Part 2 – ICD-10-CM Coding in Preventive Medicine 

Part 3 – Pediatric Preventive Medicine – Vaccine Administration


ICD-10-CM Coding in Preventive Medicine

Routine examinations such as annual physicals, general health check-ups, and well-child visits are typically assigned Z codes to describe encounters that are preventive or otherwise routine in nature. The codes/categories for routine examinations are not used when an encounter’s purpose is to diagnose a suspected condition or for treatment of a known condition.

Abnormal Findings

If an illness or abnormal finding is discovered and addressed during a routine examination encounter, it should be assigned an additional code. If a chronic or other pre-existing condition is also addressed, additional diagnosis code(s) may be assigned. In both instances, the preventive, routine health examination Z code would be reported as first listed since that describes the reason for the encounter.

Diagnosis codes for routine health examinations for children and adults distinguish between “with” and “without” abnormal findings. The use of an ICD-10-CM code that denotes “with abnormal findings” does not mean that an additional E/M service must or can be billed. Abnormal findings can be trivial or incidental issues that do not require additional work; however, the condition is still documented as a finding for the encounter.

A stable chronic condition, whether addressed or not, would not warrant the use of an abnormal findings code as it was established prior to the visit.

Adult periodic examination or annual physical (18 years or older):

  • 00 – Encounter for general adult medical examination without abnormal findings
  • 01 – Encounter for general adult medical examination with abnormal findings (Use additional code to identify any abnormal findings)

Child routine health examination for child over 28 days old (29 days through 17 years of age):

  • 121 – Encounter for routine child health examination with abnormal findings
  • 129 – Encounter for routine child health examination without abnormal findings (Use additional code to identify any abnormal findings)

This concept does not apply when the routine encounter is for a newborn infant under 29 days old. These encounters are coded based on the newborn’s age depending upon whether the infant is under 8 days old or between 8 and 28 days old and the ICD-10-CM codes do not distinguish between with or without abnormal findings.

Newborn health examination for infant under 29 days old: (Use additional code to identify any abnormal findings)

  • 110 – Health examination for newborn under 8 days old
  • 111 – Health examination for newborn 8-28 days old

ICD-10-CM Guidelines Used for Assigning Additional Codes

ICD-10-CM Official Guidelines for Coding and Reporting should be used when assigning additional diagnosis codes. For example, signs and symptoms that are routinely associated with a disease process should not be assigned as additional codes. Likewise, if a definitive diagnosis has not been established by the provider, codes for signs and symptoms are acceptable.

Diagnosis Coding for Vaccines

If a vaccination is given during a routine preventive encounter, a common practice in well-child visits, code Z23 for encounter for immunization, may be used as a secondary diagnosis code. Part 3 of this series will dive deeper into pediatric preventive medicine, with a focus on vaccine administration documentation and coding.

At The Rybar Group, our experienced and knowledgeable audit team can provide customized, value-added services to meet your compliance program requirements. Our comprehensive documentation and coding audit services are performed in a creative, constructive, and efficient manner, offering education tailored to your practice. Contact us today to inquire about our chart auditing and provider education services.

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