ICD-10 Code for Medicare Patient Establishing Care
For a Medicare patient establishing care without a specific complaint, use ICD-10 code Z00.00 (encounter for general adult medical examination without abnormal findings) or Z00.01 (encounter for general adult medical examination with abnormal findings, if any issues are identified during the visit).
Primary Code Selection
- The appropriate ICD-10 code for a new patient establishing care is Z00.00 when no specific complaints or abnormal findings are present 1
- If any abnormal findings are identified during the initial visit, use Z00.01 instead 1
- These codes fall under the "Z codes" category, which are used for encounters when circumstances other than disease or injury are documented 1
Medicare-Specific Considerations
- Medicare requires a specific ICD-10 diagnosis code on all claims to ensure seamless processing and reimbursement 1
- The referring or treating physician must assign the diagnosis code, as it is outside the scope of practice for other healthcare professionals to determine medical diagnoses 1
- Clearly document that the visit is "medically necessary and/or preventative" to facilitate proper claim processing 1
Documentation Requirements
- Document the comprehensive nature of the initial visit, including complete history, physical examination, and any screening tests performed 1
- Record baseline vital signs, review of systems, and establishment of care plan 1
- Note any chronic conditions identified or discussed during the visit, which may require additional ICD-10 codes as secondary diagnoses 1
Common Pitfalls to Avoid
- Do not leave the diagnosis field blank - Medicare will reject claims without a valid ICD-10 code 1
- Avoid using vague or non-specific codes when a more precise code exists 2, 3
- Do not confuse "establishing care" codes with "routine health maintenance" codes, which have different reimbursement implications 1
- Ensure the code matches the documentation - if specific problems are addressed during the visit, those should be coded as primary or secondary diagnoses rather than relying solely on the Z00 codes 4
Additional Coding Considerations
- If the patient has known chronic conditions discussed during the visit (such as hypertension, diabetes), these should be coded as additional diagnoses alongside the Z00 code 1
- The Z00 codes are appropriate for initial comprehensive evaluations but should not be used for subsequent follow-up visits addressing specific conditions 1
- For Medicare patients, proper ICD-10 coding directly impacts reimbursement and quality reporting metrics 1