From the Research
For an annual wellness visit, use code Z00.00 (Encounter for general adult medical examination without abnormal findings) or Z00.01 (Encounter for general adult medical examination with abnormal findings), and include additional codes for chronic conditions like diabetes (E11.9 for Type 2 diabetes without complications) as secondary diagnoses, with no strict limit on the number of codes, but prioritize relevant, active conditions that were addressed or impacted the visit. When coding, list the most relevant conditions first, typically including 3-5 codes total, but this can vary based on the patient's complexity, as seen in studies such as 1. The primary focus should remain on the preventive nature of the wellness exam, while also allowing for proper documentation of the patient's health status and any ongoing management discussed during the visit, as supported by research like 2 and 3. It's essential to ensure that coding accurately reflects the encounter and follows current guidelines for specificity and medical necessity, as emphasized in studies like 4 and 5. Key considerations include:
- Using the 4Ms framework (what matters, medication, mentation, and mobility) in RN-led annual wellness visits to enhance patient care, as explored in 1
- Increasing patient access to primary care providers through RN-led visits, as demonstrated in 1
- Improving patient outcomes and contributing to practice revenue through effective coding and documentation, as discussed in 3 and 5
- Elevating nursing standards in the ambulatory setting by expanding the role of RNs in Medicare annual wellness visits, as argued in 5