Most adults have a list of annual checkups and exams that must be performed each year so that they can be assessed for common medical conditions related to age, gender, family history, environment, and so on. These are often different for men and women, and coding the annuals is based on a variety of factors such as gender, previous history, and findings.

Some codes remain the same for both genders. This should be noted based on the exam type and related relevant findings. This list excludes mammograms and prostate exams, with and without abnormal findings, which are often coded based on relevant family history, patient history, and a variety of other factors.

Yearly Checkup—General

For both male and female patients between the ages of 15 and 124, the yearly exam ICD-10 code is the same so long as no abnormal results or findings were noted. This should apply to annual medical checkups and vision/eye[1] checkups.

Z00.00: Encounter for general adult medical examination without abnormal findings[2]

The following back references may also be applicable, depending on the respective medical history of the patient:

  • Z00-Z99: Factors influencing health status and contact with health services
  • Z00-Z13: Persons encountering health services for examinations
  • Z00: Encounter for general examination without complaint, suspected or reported diagnosis
  • 0: Encounter for general adult medical examination
  • Z01: Encounter for other special examination without complaint, suspected or reported diagnosis
  • 0: Encounter for examination of eyes and vision

In addition, these synonyms may or may not be present: Adult health check up done, Laboratory exam, Laboratory exam ordered for general medical exam, Laboratory examination done, Radiological exam, Radiological examination done, Routine adult health check up exam, Routine general medical exam order for laboratory test done.

For routine/annual eye and vision exams, the following synonyms may also apply: Emmetropia; Emmetropia (eye condition); Encounter for exam of eyes and vision-normal findings; Examination of eyes and vision-normal findings done; Eye and vision exam normal; Eye and vision exam, routine, normal findings; Eye exam, problem focused with normal findings; Glaucomatous optic atrophy; Large physiologic cupping of optic disc; Normal vision; Optic nerve cupping; Physiologic cupping of optic disc; Problem focused eye exam with normal findings; Routine child vision test; Routine child vision testing done; Visual acuity screening; Visual acuity screening done.

Z00.01: …… with abnormal findings[3] (exempt from POA recording)

        The same back references are applicable for this code entry.

Z01.20: Encounter for dental examination and cleaning without abnormal findings[4]

The following back references may also be applicable to this code:

  • Z00-Z99: Factors influencing health status and contact with health services
  • Z00-Z13: Persons encountering health services for examinations

Z01.21: ……with abnormal findings

The same back references are also applicable to this code.

Z01.10: Encounter for examination of ears and hearing without abnormal findings[5]

The following back references are also applicable:

  • Z00-Z13: Persons encountering health services for examinations
  • Z01: Encounter for other special examination without complaint, suspected or reported diagnosis

Z01:11: ……with abnormal findings

The same back references are applicable to this code.

Yearly Checkups—Female

For women of all ages, the following codes are applicable:

Z01.419: Encounter for gynecological examination (general) (routine) without abnormal findings[6] (Exempt from POA recording)

The following back references may also be applicable to this code:

  • Z00-Z99: Factors influencing health status and contact with health services
  • Z00-Z13: Persons encountering health services for examinations
  • Z01: Encounter for other special examination without complaint, suspected or reported diagnosis
  • 4: Encounter for gynecological examination
  • 41: Encounter for routine gynecological examination

The following synonyms may or may not be noted, depending on the notations of the care provider: Exam, routine gyn visit, Routine gynecologic examination done, Routine gynecological exam done, Routine gynecological exam including cervical pap done, Well woman exam including screening cervical pap smear.

Z01.411: ……with abnormal findings[7]

               The same back references are also applicable to this code.

Yearly Checkups—Child

For children, a yearly checkup is the best way to record physical and mental development, immunizations, boosters, and so on. Code as follows:

Z00.129: Encounter for routine child health examination without abnormal findings[8], from birth to 17 years old

The following back references may also be applicable to this code:

  • Z00-Z99: Factors influencing health status and contact with health services
  • Z00-Z13: Persons encountering health services for examinations
  • Z00: Encounter for general examination without complaint, suspected or reported diagnosis
  • 12: Encounter for routine child health examination

The following synonyms may or may not be noted, depending on the notations of the care provider: Well adolescent care, well adolescent care done, well child care, well child care done

Z00.121: …… with abnormal findings, birth to 17 years old[9]

               The same back references may also be applicable as before.

[1] http://www.icd10data.com/ICD10CM/Codes/Z00-Z99/Z00-Z13/Z01-/Z01.00

[2] http://www.icd10data.com/ICD10CM/Codes/Z00-Z99/Z00-Z13/Z00-/Z00.00

[3] http://www.icd10data.com/ICD10CM/Codes/Z00-Z99/Z00-Z13/Z00-/Z00.01

[4] http://www.icd10data.com/ICD10CM/Codes/Z00-Z99/Z00-Z13/Z01-/Z01.20

[5] http://www.icd10data.com/ICD10CM/Codes/Z00-Z99/Z00-Z13/Z01-/Z01.10

[6] http://www.icd10data.com/ICD10CM/Codes/Z00-Z99/Z00-Z13/Z01-/Z01.419

[7] http://www.icd10data.com/ICD10CM/Codes/Z00-Z99/Z00-Z13/Z01-/Z01.411

[8] http://www.icd10data.com/ICD10CM/Codes/Z00-Z99/Z00-Z13/Z00-/Z00.129

[9] http://www.icd10data.com/ICD10CM/Codes/Z00-Z99/Z00-Z13/Z00-/Z00.121