2025 ICD-10-CM code Z00
Encounter for general examination without complaint, suspected, or reported diagnosis.
The medical necessity for a general examination is based on the patient's individual risk factors, age, and overall health status.Routine preventive examinations are generally considered medically necessary.
The clinician's responsibility is to perform a general physical examination,document findings, and provide counseling or recommendations as appropriate based on the examination.
- Factors influencing health status and contact with health services (Z00-Z99)
- Persons encountering health services for examinations (Z00-Z13)
In simple words: This code is used for a general checkup when you don't have any particular symptoms or known health problems.
This code is used for encounters with health services for a general examination when no specific complaint, suspected diagnosis, or reported diagnosis is present.It is important to note that if a procedure is performed during this encounter, a corresponding procedure code must also be used.
Example 1: A healthy adult visits their physician for a routine annual physical examination. No specific complaints are presented, and the examination reveals no abnormalities., A patient visits a clinic for a pre-employment physical required by their new employer. They have no current health concerns, and the examination is unremarkable., An individual participates in a health fair and receives a basic health check including blood pressure and weight measurements. No problems are identified.
Documentation should include the details of the physical examination performed, vital signs, and any relevant observations or assessments. If any abnormal findings are detected during the examination, they should be documented and coded separately.
** This code is a billable ICD-10-CM code. It is important to distinguish Z00 from codes related to administrative examinations (Z02.-), pre-procedural examinations (Z01.81-), and special screening examinations (Z11-Z13).
- Specialties:General practice, family medicine, internal medicine, preventive medicine
- Place of Service:Office, Outpatient Hospital, Clinic, Mobile Unit