AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2016 Issue 1; Ask the Editor
Adult Physical Examination with Abnormal Findings
An adult patient diagnosed with hypertension presents for an annual physical examination. During the visit the patient’s blood pressure is noted to be elevated, and the physician adjusts the antihypertensive meds for better control. Should this visit be coded as an exam with abnormal finding? ...
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Article Overview
This premium article discusses adult preventive physical examinations in the context of an unexpected abnormal finding identified during the visit. It is intended for medical coders and billing staff who need to understand encounter classification, supporting diagnosis coding, and the general guidance that applies when an exam reveals a new abnormality. The content focuses on how the topic is framed in coding guidance and why the encounter must be documented accurately.
Why This Topic Matters
Correctly classifying a preventive adult exam with an abnormal finding affects diagnosis selection, claim accuracy, and how the visit is represented in the medical record. This article helps readers distinguish routine examination scenarios from encounters that require additional diagnosis reporting.
What You Will Learn
- How adult annual physical examinations are classified when an abnormal finding is present
- How encounter coding relates to documentation of a newly discovered abnormality
- Why additional diagnosis reporting may be needed to support the abnormal finding
- How this topic applies to adult preventive care and hypertension-related documentation
Who Should Read This
- Medical coders
- Billing staff
- Physician practice coders
- Compliance staff
Codes Discussed
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