Encounters for general examination - Is it with or without abnormal findings?

Susan Morton, CPC, CPC-I, CEMC, CGSC, COBGC, COPC, Approved Instructor Profee Coding Leave a Comment

Encounters for general examination - Is it with or without abnormal findings?

When a provider addresses additional conditions at a general examination visit, usually referred to as a Well-Child or Adult Physical encounter, coders are often left to decide whether to assign a “with” or “without” abnormal findings code. So, how can we easily decide which code to assign? Per Coding Clinic First Quarter 2016 “For the purpose of assigning codes from this category, an “abnormal finding” is a newly discovered condition, or a known/chronic condition that has increased in severity.” When documentation supports an additional condition is being addressed during a general examination encounter, it doesn’t automatically mean that a “with abnormal finding” code should be assigned.

Coders should carefully review the documentation to determine if the condition(s) being addressed are new or have increased in severity. If the documentation supports a new or exacerbated condition(s) were addressed, a “with abnormal finding” code should be reported. When a coder determines that a new or worsening chronic condition(s) was addressed and will be assigning a “with abnormal findings” code, an additional code(s) is required to identify the abnormal findings. If a stable, chronic condition(s) is addressed at the visit, an additional code may also be reported with the “without abnormal findings” code, if the documentation supports the condition(s) was addressed at the encounter.

Example: A 56-year-old man is seen for his yearly physical exam. During the visit, the provider addressed his chronic conditions which include hypertension, hyperlipidemia, and diabetes, all of which are documented as stable and no adjustments in treatment are documented. In this case, the coder should assign code Z00.00 (encounter for general adult medical examination without abnormal findings) along with the appropriate codes for hypertension, hyperlipidemia, and diabetes.

Example: A 3-year-old girl is seen for her well child exam. During the encounter, the patient’s mother mentions to the provider the patient has been coughing for the last couple of days and has a known diagnosis of asthma. During the examination, the provider notes wheezing with occasional cough. The child is diagnosed with an asthma exacerbation. The provider starts the patient on an oral steroid and increased her routine asthma medications. In this case, the coder should assign code Z00.121 (encounter for routine child health examination with abnormal findings) along with the appropriate code for asthma exacerbation.

It should be noted that this article is only addressing ICD-10-CM code assignment. Coders should remember that reporting additional findings/diagnoses ICD-10-CM codes during a preventive exam does not automatically mean that an additional Evaluation and Management Code should be reported. Coders should familiarize themselves with the rules for reporting preventive medicine visits with sick visits, as the E/M does require significant and separately identifiable services to be documented. Coding guidelines and rules should be understood before reporting services.

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