Updated on: July 26, 2025
Annual wellness exams are essential for preventive care, risk stratification, and patient engagement. When any abnormal finding arises during a general adult exam—whether it’s elevated blood pressure, an abnormal mole, or a murmur—clinicians must transition from using Z00.00 to Z00.01 for billing and documentation accuracy.
This article offers a full guide to when and how to use Z00.01, how to pair it with secondary diagnosis codes, and how to maintain billing compliance while delivering excellent care.
What Is ICD-10 Code Z00.01?
Z00.01 is used when:
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A patient is seen for a general adult exam
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Any abnormal finding is discovered during that visit
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These abnormalities may be symptomatic or asymptomatic, benign or serious
The abnormal finding does not need to be the primary reason for the visit—it can be incidental but must be clinically relevant.
Common Examples of When to Use Z00.01
| Scenario | Use Z00.01? | Additional ICD-10 Code Example |
|---|---|---|
| Elevated BP noted during exam | ✅ Yes | R03.0 – Elevated BP, no diagnosis |
| Mole found requiring derm referral | ✅ Yes | D48.5 – Neoplasm of uncertain behavior |
| Heart murmur detected | ✅ Yes | R01.1 – Cardiac murmur |
| Vaginal discharge noted | ✅ Yes | N89.8 – Other specified disorders |
| Depression screen positive | ✅ Yes | Z13.89 + F32.9 – MDD, if diagnosed |
Z00.01 vs Z00.00: Know the Difference
| Z00.00 | Z00.01 |
|---|---|
| Preventive exam with no abnormal findings | Preventive exam with abnormal findings |
| Use when exam is entirely normal | Use when anything clinically notable is found |
| Not typically paired with symptom codes | Often paired with codes like R03.0, R21, etc. |
| Most routine well visits | More detailed documentation required |
Documentation Requirements for Z00.01
When using Z00.01, include:
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A full physical exam and review of systems
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Description of the abnormal finding
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Assessment/plan for follow-up or investigation
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Any referrals, labs, or imaging ordered
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Health maintenance (e.g., immunizations, counseling)
Sample EHR Note:
“35-year-old male presents for routine annual exam. Physical exam notable for blood pressure of 146/92. No prior diagnosis of hypertension. Plan includes home BP monitoring and repeat in 2 weeks. Diagnosis: Z00.01 + R03.0.”
SOAP Note Example – General Exam With Abnormal Findings
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S: “No complaints. Here for routine check-up.”
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O: Physical exam reveals systolic BP >140 on two readings; all other systems WNL.
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A: General adult medical exam with abnormal BP reading (Z00.01 + R03.0)
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P: Educate on DASH diet; recheck BP in 2 weeks; consider ambulatory BP monitoring
Billing and CPT Code Pairing
Common CPT Codes for Annual Exams:
| Age Group | New Patient | Established Patient |
|---|---|---|
| 18–39 yrs | 99385 | 99395 |
| 40–64 yrs | 99386 | 99396 |
| 65+ yrs | 99387 | 99397 |
Z00.01 should replace Z00.00 when billed with any of the above codes if abnormal findings are present.
Additional Codes to Pair With Z00.01
| Finding | ICD-10 Code |
|---|---|
| Elevated BP | R03.0 |
| Skin lesion | D48.5 |
| Anemia (from labs) | D50.9 |
| Depression screen positive | F32.9 |
| High BMI | Z68.3x |
| Hyperlipidemia | E78.5 |
| Newly discovered heart murmur | R01.1 |
Add these codes as secondary diagnoses to Z00.01 to ensure complete documentation and billing accuracy.
Counseling and Preventive Elements to Include
Even with an abnormal finding, preventive care remains a key component:
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Vaccination status (e.g., influenza, shingles, COVID-19)
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Tobacco/alcohol counseling (Z71.41 / Z71.89)
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Screening orders (e.g., colonoscopy, mammogram)
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Nutrition and physical activity discussion
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Family history updates
Coding FAQs
Can I use Z00.01 for Medicare annual wellness visits (AWV)?
No. Use G0438 or G0439 for Medicare AWVs. Z00.01 is used for commercial insurance annual physicals with abnormal findings.
What if the patient has multiple abnormal findings?
Use Z00.01 as the primary diagnosis, and add all relevant findings as secondary codes.
What if the abnormal finding is minor and requires no follow-up?
Still use Z00.01 if the clinician made a clinical note of the finding—even if no intervention is needed.
How DocScrib Enhances Z00.01 Visit Documentation
DocScrib’s AI-powered platform helps clinicians:
✅ Automatically detect abnormal findings during SOAP note creation
✅ Suggest Z00.01 + applicable symptom or condition codes
✅ Generate complete, audit-compliant preventive visit notes
✅ Reduce note-taking time while improving billing precision
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Conclusion
ICD-10 code Z00.01 is critical when any abnormality is discovered during a routine adult exam—even if it’s incidental. Clinicians should document all findings thoroughly and pair Z00.01 with accurate secondary codes to reflect a complete clinical picture. With DocScrib, that process becomes easier, faster, and more accurate—supporting high-quality, compliant care.