Encounter for general adult medical examination without abnormal findings
ICD-10 Z00.00 is a billable code used to indicate a diagnosis of encounter for general adult medical examination without abnormal findings.
Z00.00 is used to document an encounter for a general adult medical examination where no abnormal findings are noted. This code is essential for preventive care, as it reflects the importance of routine health assessments in identifying potential health risks early. During such examinations, healthcare providers assess various health determinants, including lifestyle factors, social determinants of health (SDOH), and mental well-being. The absence of abnormal findings indicates that the patient is in good health, which can be influenced by factors such as socioeconomic status, access to healthcare, and community resources. Preventive screenings, such as blood pressure checks, cholesterol levels, and cancer screenings, may be performed during this visit, contributing to the overall health status of the individual. Proper documentation of these encounters is crucial for ensuring continuity of care and for meeting payer requirements for preventive services.
Documentation should include a comprehensive review of systems, vital signs, and any preventive services provided.
Routine checkups, annual physicals, and preventive screenings such as mammograms or colonoscopies.
Consideration of social determinants such as access to care, lifestyle factors, and mental health status.
Documentation should include population health data, surveillance of health trends, and preventive measures taken.
Community health screenings, vaccination drives, and health fairs.
Focus on health equity and addressing barriers to care in underserved populations.
Used in conjunction with Z00.00 for a new patient undergoing a preventive examination.
Documentation must include a comprehensive history, examination, and counseling on preventive services.
Primary care providers should ensure all preventive services are documented.
Documentation should include a complete history and physical examination, vital signs, and any preventive services performed, clearly indicating that there were no abnormal findings.
