ICD-10-CM guide
Coding a Routine Physical: Z00.00 vs Z00.01 and Screening Codes
When to report Z00.00 or Z00.01 for an annual adult exam, what counts as an abnormal finding, and how screening Z codes fit alongside the exam code.
Reviewed 2026-10-20 | 4 min read
A routine physical looks like the easiest encounter to code: the patient came in for a check-up, so the code is a check-up code. The decisions come after that. Did the exam turn up something new or worse? Was a screening test ordered? Were chronic conditions managed? Each answer changes the code set, and in one case it changes which code goes first.
What a routine exam code covers
Z00.0- describes a general adult examination without a complaint, suspected diagnosis, or reported diagnosis. It is not for a visit to diagnose a suspected condition or to treat one. The Tabular List excludes an examination of a sign or symptom from Z00.0- and directs you to code the sign or symptom instead.
Z00.00 or Z00.01
Z00.00 is the adult exam without abnormal findings. Z00.01 is the adult exam with abnormal findings. An abnormal finding means a condition or diagnosis that is newly identified during the exam, or a change in severity of a chronic condition, such as uncontrolled hypertension or an acute exacerbation of COPD.
When the exam has an abnormal finding, Z00.01 is first-listed and a secondary code identifies the finding. A stable chronic condition that is simply reviewed does not make the exam abnormal.
Code from what is known when you code. If nothing abnormal was found and test results are still pending, Z00.00 is acceptable.
Chronic conditions at an annual exam
Most adults who come in for a physical have at least one chronic condition, so the real question is whether the condition changed. The code choice follows what the provider documents about it during the exam.
- A chronic condition reviewed and documented as stable, with the current plan continued: Z00.00 first, and the chronic condition may be added as an additional code.
- A chronic condition documented as worse, such as hypertension now uncontrolled: Z00.01 first, with the code for the condition as the abnormal finding.
- A condition newly identified during the exam, including one confirmed by results available when you code: Z00.01 first, with the code for the new condition.
- No abnormal findings on the exam and test results still pending: Z00.00 is acceptable.
- Z00.01 is never listed after the condition. Category Z00 codes may only be reported as the first-listed diagnosis.
Other conditions can be added
During a routine exam, a newly discovered condition is coded as an additional code. Pre-existing and chronic conditions and history codes may also be added, as long as the exam is not focused on any particular condition.
Screening is not the same as diagnostic testing
Screening is testing for disease in a person who appears well, such as a screening test for diabetes. Testing because a patient has a sign or symptom is diagnostic, not screening. In that case the sign or symptom explains the test.
- A screening code can be first-listed when the visit is specifically for the screening.
- A screening code can be added when the screening is done during a visit for other reasons, including a routine exam. For example, a diabetes screening ordered at an annual physical is Z13.1 after the exam code.
- A screening code is not needed when the screening is inherent to the routine exam itself.
- If the screening finds a condition, that condition may be coded as an additional diagnosis.
A routine exam decision path
- Was the visit for a general check-up, not a complaint? Start with Z00.0-.
- Was a condition newly identified, or did a chronic condition worsen? Use Z00.01 and add the code for the finding.
- Was a separate screening test ordered for a seemingly well patient? Add the screening Z code.
- Were stable chronic conditions addressed? They may be added as additional codes.
Questions coders ask
- What is the difference between Z00.00 and Z00.01?
- Z00.00 is a general adult exam without abnormal findings. Z00.01 is used when the exam newly identifies a condition or finds a change in severity of a chronic condition, and it requires an additional code for the finding.
- Does a stable chronic condition make the exam abnormal?
- No. An abnormal finding is a newly identified condition or a change in severity. A stable chronic condition may be coded as an additional code without switching to Z00.01.
- Is a screening test at a physical coded separately?
- Often, yes. A screening Z code can be added when a screening test is done during the visit, unless the screening is inherent to the routine exam.
- Can Z00.01 be listed after the abnormal finding?
- No. The guidelines assign Z00.01 as the first-listed diagnosis when the exam has an abnormal finding, and category Z00 is on the list of Z codes that may only be reported first. The finding follows as a secondary code.
- Can a routine exam code be used when the patient has a complaint?
- No. When the visit is to evaluate a sign, symptom, or suspected condition, code the sign, symptom, or diagnosis instead of Z00.0-.
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Sources
ICD-10-CM Official Guidelines for Coding and Reporting FY 2027
Section IV.P, Encounters for general medical examinations with abnormal findings
ICD-10-CM Official Guidelines for Coding and Reporting FY 2027
Section I.C.21.c.12, Routine and Administrative Examinations
ICD-10-CM Official Guidelines for Coding and Reporting FY 2027
Section I.C.21.c.15, Z Codes That May Only be Principal/First-Listed Diagnosis
ICD-10-CM Official Guidelines for Coding and Reporting FY 2027
Section I.C.21.c.5, Screening
FY 2027 ICD-10-CM Tabular List and Alphabetic Index
Tabular List, subcategory Z00.0 and code Z00.01
FY 2027 ICD-10-CM Code Descriptions in Tabular Order
Codes Z00.00, Z00.01, Z13.1