Establishing Care (Z00.00): A Clinician’s Guide to ICD-10 Coding and Documentation for New Patient Encounters

Updated on: July 26, 2025

“Establishing care” is one of the most frequent reasons for new patient visits in primary care, internal medicine, and family practice settings. Whether a patient is transferring from another provider or attending their first check-up in years, proper documentation is essential for compliance, quality metrics, and billing.

The correct ICD-10 code for most routine, preventive ‘establish care’ visits without complaints is Z00.00. This guide helps clinicians use it correctly, document it thoroughly, and know when to pivot to other codes if abnormalities are found.

What Does ICD-10 Code Z00.00 Represent?

Z00.00 is used when:

• A patient comes in for a general wellness or preventive visit

• No abnormal findings are noted during the exam

• There is no acute complaint, chronic disease management, or risk factor screening triggering a different diagnosis code

It reflects a standard adult physical exam, often associated with first-time or routine annual visits.

Key Situations to Use Z00.00

Documentation Requirements for Z00.00

To bill a Z00.00 encounter, ensure documentation includes:

• Complete review of systems (ROS)

• Comprehensive physical exam

• Health maintenance and counseling

• Immunization status review

• Risk screening (tobacco, alcohol, safety)

• Family history, social history, and medications

Even if the patient is “healthy,” your EHR should reflect a full evaluation for audit protection and payer compliance.

Sample EHR Note – Establish Care Visit

CC: “Establishing care, no complaints today”
HPI: 32-year-old female, new to clinic, no acute symptoms. Last physical 2 years ago.
ROS: Negative for fatigue, chest pain, cough, etc.
PE: Vitals normal. Heart/lungs/abdomen WNL.
A: Healthy adult female; no acute or chronic concerns
P: Document health history, update immunizations, recommended screening labs. Diagnosis: Z00.00.

When to Use Z00.01 Instead

Use Z00.01 when any abnormal findings are documented—even if they’re mild, unrelated, or asymptomatic.

Examples:

• Elevated BP noted on exam → use Z00.01 + R03.0

• Suspicious mole found → use Z00.01 + D48.5

• Lab abnormality (e.g., borderline cholesterol) → Z00.01 + E78.0

Add-On Screening & Risk Codes

You can pair Z00.00 with additional Z codes for preventive services:

Billing Considerations

CPT Codes Often Billed with Z00.00:

• 99385–99387 (New patient, age-based)

• 99395–99397 (Established patient, age-based)

• 99401–99404 (Preventive counseling)

Note: Z00.00 is diagnosis, not procedure. Combine with age-appropriate CPTs and document time when applicable.

FAQs About Establishing Care (Z00.00)

Can I use Z00.00 with Medicare patients?

No. For Medicare annual wellness visits (AWVs), use G0402, G0438, or G0439. However, Z00.00 may be used for commercial preventive exams.

What if patient mentions back pain during visit?

If the visit shifts into problem-based evaluation, add M54.5 for back pain and consider splitting the visit into preventive + problem components.

Can Z00.00 be used in telehealth?

Yes, if a comprehensive virtual exam is performed, though preventive physicals are usually done in person.

How DocScrib Enhances New Patient Visits

✅ Auto-fill Z00.00 encounters based on templates
✅ Capture full ROS, PE, and patient history
✅ Suggest additional Z codes for screenings
✅ Generate compliant, billable SOAP notes

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Conclusion

ICD-10 code Z00.00 is essential for documenting and billing establish care visits when patients are asymptomatic and seeking preventive services. As long as you conduct a complete assessment and record it thoroughly, this code supports compliance, quality reporting, and continuity of care. With help from tools like DocScrib, establishing care has never been easier—or more efficient.