Z00.00

Encounter for general adult medical examination without abnormal findings

Factors influencing health status and contact with health services Billable
Quick Reference
Annual physical exam or wellness visit without abnormal findings

Clinical Information

When to Use This Code

Annual physical exam or wellness visit without abnormal findings

Common Clinical Scenarios

  • Annual physical examination
  • Preventive health screening
  • Wellness visit without problems identified
  • Medicare Annual Wellness Visit

Documentation Requirements

  • Document comprehensive physical exam performed
  • Record vital signs, BMI, review of systems
  • Note preventive counseling provided
  • List age-appropriate screening tests completed
  • Use Z00.01 if abnormal findings discovered

Coding Guidelines

Inclusion Terms

These terms are included in this code:

Annual physicalHealth maintenance examPreventive visitCheck-up

Exclusion Terms

Do NOT use this code for:

  • Exam with abnormal findings (Z00.01)
  • Encounter for administrative purposes (Z02.-)

Coding Notes

Use Z00.01 when abnormalities found during exam
Cannot be used with problem-oriented E/M on same day
For Medicare AWV, use G0438 or G0439 instead

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Code Details

Code
Z00.00
Category
Factors influencing health status and contact with health services
Billable Status
Billable

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