ICD-10 Coding for Physical Examination with Patient Declining Laboratory Tests
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) depending on your examination findings, even when the patient declines laboratory testing.
Primary Code Selection
- Z00.00 is appropriate when your physical examination reveals no abnormal findings and the patient declines labs 1
- Z00.01 should be used if your physical examination identifies any abnormal findings requiring follow-up, regardless of lab refusal 1
- These codes specifically cover routine general medical examinations in adults and do not require laboratory testing to be valid 1
Key Coding Principles
The patient's refusal of specific services does not change the primary encounter code. The examination you performed still constitutes a general adult medical examination, which is what you should code 1, 2.
Additional Considerations
- Do not use well-woman exam codes (Z01.41x series) since the patient explicitly states she receives this service elsewhere and this is not the purpose of your encounter 1
- Document the patient's refusal of laboratory testing in the medical record, but this refusal does not require a separate ICD-10 code 3
- The patient's right to decline recommended services is well-established and should be respected and documented 3
Documentation Requirements
Your medical record should clearly state:
- The scope of the physical examination you performed 1
- That laboratory testing was discussed and declined by the patient 3
- The patient's stated reason (already receives well-woman care elsewhere) 3
- Any abnormal findings from your physical examination that would justify Z00.01 over Z00.00 1
Common Pitfalls to Avoid
- Do not code for services not performed - if labs weren't done, don't use codes that imply comprehensive screening was completed 4, 5
- Do not use Z53.20 (procedure not carried out due to patient decision) as a primary code - this is a secondary code and doesn't accurately reflect that you completed a physical examination 5
- Avoid mixing preventive and problem-focused codes unless you addressed specific complaints during the same visit 5
If Abnormal Findings Are Present
When using Z00.01, also code any specific abnormal findings identified during your examination (e.g., elevated blood pressure, abnormal heart sounds) as secondary diagnoses to provide complete documentation 3, 5.