Z00.00
Encounter for general adult medical examination without abnormal findings
ICD-10 code Z00.00 is a clinical classification used for an encounter where an adult patient presents for a routine general medical examination, such as an annual physical, and the provider finds no new illnesses, abnormal findings, or significant changes in pre-existing conditions during the evaluation. This code is designated for preventive health maintenance and includes a history, physical examination, and age-appropriate counseling or screening recommendations. If an abnormal finding is discovered during the visit, or if the visit was intended to address a specific symptom, a different code (typically Z00.01) would be appropriate. This code is fundamental in capturing data for population health and preventive services metrics.
Clinical Symptoms
- Asymptomatic
- Routine health maintenance visit
- No acute physical complaints
- Stable chronic conditions without exacerbation
Common Causes
- Age-appropriate preventive health screening
- Employer-mandated physical examination
- Patient-initiated wellness evaluation
- Health insurance requirement for wellness benefit
Documentation & Coding Tips
Explicitly document the absence of any new or significant abnormal findings discovered during the history or physical examination.
Example: Documentation states: 'Patient presents for annual physical. ROS is negative. Physical exam is within normal limits. No new findings identified.'
Distinguish this code from Z00.01, which is used if an abnormal finding is discovered during the routine exam.
Example: If a new heart murmur is heard during a routine physical, use Z00.01 instead of Z00.00.
Ensure the patient meets the clinical definition of an 'adult' (typically 18 years or older) for this specific code.
Example: For a 17-year-old, use the appropriate pediatric code series (Z00.12x).
Chronic conditions may be documented, but Z00.00 is only applicable if those conditions are stable and not the primary focus of the examination or showing new abnormalities.
Example: Patient has stable hypertension; the physical exam reveals controlled BP and no new symptoms. Z00.00 remains appropriate as the primary code.
Relevant CPT Codes
- 99395 - Periodic preventive medicine reevaluation and management, established patient, 18-39 years
- 99396 - Periodic preventive medicine reevaluation and management, established patient, 40-64 years
- 99385 - Initial preventive medicine evaluation and management, new patient, 18-39 years
- G0438 - Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit
Related Diagnoses
- Z00.01 - Encounter for general adult medical examination with abnormal findings
- Z01.419 - Encounter for gynecological examination (general) (routine) without abnormal findings
- Z00.129 - Encounter for routine child health examination without abnormal findings
- Z02.0 - Encounter for examination for admission to educational institution
Hierarchy
- Chapter 21 - Factors influencing health status and contact with health services (Z00-Z99)
- Z00-Z13 - Persons encountering health services for examinations
- Z00 - Encounter for general examination and investigation of persons without complaint and suspected or reported diagnosis
- Z00.0 - Encounter for general medical examination
- Z00.00 - Encounter for general adult medical examination without abnormal findings