Understanding Physical Exam ICD-10 Codes
Accurate coding for physical examinations is essential for proper reimbursement and compliance. The ICD-10-CM system provides specific codes for different types of examinations, while CPT and HCPCS codes determine the type of service provided. This guide covers the complete 2026 coding requirements for physical exams, preventive visits, and Medicare wellness encounters.
The 2026 edition of ICD-10-CM became effective on October 1, 2025, with no significant changes to the Z00 code family for general examinations. However, understanding the nuances of when to use each code remains critical for clean claims and optimal reimbursement.
Adult Physical Exam ICD-10 Codes
Z00.00 - General Adult Medical Examination Without Abnormal Findings
This is the primary code for routine annual physical examinations when no new diagnoses or significant findings are discovered. It's a billable, specific code that can be used for reimbursement.
When to Use Z00.00:
- Routine annual wellness exams with no abnormalities
- Pre-employment physicals with normal results
- Insurance-required physicals without findings
- Stable chronic conditions (part of history, not new findings)
Z00.01 - General Adult Medical Examination With Abnormal Findings
Use this code when the examination identifies any issues that require further evaluation, even minor ones. The abnormal findings are then reported as additional diagnosis codes.
What Qualifies as "Abnormal Findings":
- Newly identified conditions (elevated blood pressure, abnormal labs)
- Change in severity of chronic conditions (uncontrolled HTN)
- Suspicious lesions or masses requiring follow-up
- Acute exacerbation of chronic conditions (COPD flare)
Coding Example
A 45-year-old patient presents for an annual physical. During the exam, you discover elevated blood pressure (150/95) and a suspicious mole on the back.
Primary: Z00.01 - General adult exam with abnormal findings
Secondary: R03.0 - Elevated blood pressure reading
Secondary: D22.5 - Melanocytic nevi of trunk
Pediatric Well-Child Exam ICD-10 Codes
| Code | Description | Age Range |
|---|---|---|
| Z00.110 | Health exam for newborn under 8 days old | 0-7 days |
| Z00.111 | Health exam for newborn 8 to 28 days old | 8-28 days |
| Z00.129 | Routine child health exam without abnormal findings | 29 days - 17 years |
| Z00.121 | Routine child health exam with abnormal findings | 29 days - 17 years |
Documentation Tip
For pediatric visits, document developmental milestones, growth parameters (height, weight, BMI percentile), and age-appropriate screenings. If using Z00.121, clearly document what abnormal findings were identified, such as growth delays, developmental concerns, or abnormal BMI.
Preventive Visit CPT Codes (99381-99397)
CPT provides two sets of preventive medicine codes based on patient status: new patients (99381-99387) and established patients (99391-99397). The age ranges determine which specific code to use.
New Patient Codes
| 99381 | Infant (<1 year) |
| 99382 | Early childhood (1-4) |
| 99383 | Late childhood (5-11) |
| 99384 | Adolescent (12-17) |
| 99385 | Young adult (18-39) |
| 99386 | Adult (40-64) |
| 99387 | Elderly (65+) |
Established Patient Codes
| 99391 | Infant (<1 year) |
| 99392 | Early childhood (1-4) |
| 99393 | Late childhood (5-11) |
| 99394 | Adolescent (12-17) |
| 99395 | Young adult (18-39) |
| 99396 | Adult (40-64) |
| 99397 | Elderly (65+) |
The Three-Year Rule
A patient is considered "new" if they have not been seen by any physician of the same specialty in the same group within the past 36 months. All other patients are "established." This rule determines whether to use the 9938x or 9939x series.
Medicare Annual Wellness Visit (AWV) Codes
Traditional Medicare does not cover the preventive CPT codes 99381-99397. Instead, Medicare has its own wellness visit codes with specific requirements and eligibility criteria.
G0402 - Initial Preventive Physical Examination (IPPE)
Also known as the "Welcome to Medicare" visit. This is a one-time benefit available within the first 12 months of Medicare Part B enrollment.
Required Components:
- • Review of medical and social history
- • Review of potential risk factors for depression
- • Review of functional ability and safety
- • Height, weight, blood pressure, visual acuity
- • End-of-life planning (with patient permission)
- • Education, counseling, and referrals
G0438 - Initial Annual Wellness Visit
The first AWV after at least 12 months of Part B coverage. This code can only be billed once in a patient's lifetime.
G0439 - Subsequent Annual Wellness Visit
Used for every AWV after the initial one, no more than once every 12 months. This is the recurring AWV code.
Common Billing Mistake
Using G0439 instead of G0438 for the initial AWV results in approximately $34 less reimbursement per visit. Ensure your EHR flags patients who are eligible for their first AWV to maximize proper code selection.
AWV Add-On Services
| Code | Description | Eligible With |
|---|---|---|
| G0444 | Annual depression screening (15 min) | G0439 only |
| G0389 | AAA screening | G0402 only |
| G0447 | Obesity counseling (15 min) | G0402, G0438, G0439 |
| G0403 | ECG | G0402 only |
Same-Day Problem Visit: Using Modifier 25
When a significant, separately identifiable problem is addressed during a preventive visit, you may bill both services. The problem-oriented E/M code (99202-99215) requires modifier 25.
When Modifier 25 is Appropriate
DO Use Modifier 25
- New acute symptoms discovered during exam
- Complex medication adjustments requiring significant work
- New diagnosis requiring evaluation and treatment planning
- Chronic disease exacerbation needing management changes
DON'T Use Modifier 25
- Routine refills of stable medications
- Brief review of stable chronic conditions
- Minor complaints that don't require significant work
- Status review of controlled hypertension/diabetes
2025 Medicare Update: G2211
Beginning January 1, 2025, Medicare allows payment for G2211 (complexity add-on) when the base E/M service is appended with modifier 25 and provided on the same date as an annual wellness visit. This represents additional reimbursement for complex longitudinal care.
Documentation Best Practices
- 1Separate documentation - Physically separate the preventive and problem-oriented documentation using distinct headers
- 2Demonstrate medical necessity - Document why the problem required additional evaluation beyond the preventive service
- 3Clear diagnosis codes - Use Z00.01 for the preventive portion and specific ICD-10 codes for the problems addressed
- 4Inform patients - Explain that the additional service may be subject to copay/deductible
Other Physical Exam ICD-10 Codes
| Code | Description | Use Case |
|---|---|---|
| Z01.411 | Gynecological exam (routine) without abnormal findings | Annual GYN exam, pelvic exam |
| Z01.419 | Gynecological exam (routine) with abnormal findings | GYN exam with positive findings |
| Z02.0 | Examination for admission to educational institution | School physicals, college entrance |
| Z02.1 | Pre-employment examination | Job-related physicals |
| Z02.3 | Examination for recruitment to armed forces | Military entrance physicals |
| Z02.5 | Examination for participation in sport | Sports physicals |
| Z02.6 | Examination for insurance purposes | Life insurance, disability exams |
| Z02.71 | Examination for disability determination | SSA disability evaluations |
| Z02.89 | Other administrative examinations | Driver's license, camp physicals |
Frequently Asked Questions
What is the difference between Z00.00 and Z00.01?
Z00.00 is for a general adult medical examination without abnormal findings, while Z00.01 is for the same exam with abnormal findings. If any new diagnoses or significant changes to existing conditions are discovered, use Z00.01 as the primary code and list the abnormal findings as secondary codes.
Does Medicare cover the preventive CPT codes 99381-99397?
No, traditional Medicare does not cover CPT codes 99381-99397. Medicare has its own wellness visit codes: G0402 (Welcome to Medicare), G0438 (Initial AWV), and G0439 (Subsequent AWV). However, some Medicare Advantage plans may cover the preventive CPT codes in addition to Medicare wellness visits.
When should I use modifier 25 with a preventive visit?
Use modifier 25 on a problem-oriented E/M code (99202-99215) when you perform a significant, separately identifiable evaluation and management service on the same day as a preventive visit. The problem must require additional work beyond the preventive service and be clearly documented separately.
What is the difference between G0438 and G0439?
G0438 is the Initial Annual Wellness Visit, used once per lifetime after a patient has been enrolled in Medicare Part B for at least 12 months. G0439 is the Subsequent Annual Wellness Visit, used for every AWV after the initial one, no more than once every 12 months.
Which ICD-10 codes should I use for pediatric well-child visits?
For newborns, use Z00.110 (under 8 days) or Z00.111 (8-28 days). For children 29 days and older, use Z00.129 (without abnormal findings) or Z00.121 (with abnormal findings). These codes are age-appropriate for patients 0-17 years.
How do I code when abnormal findings are discovered during an annual exam?
When abnormal findings are discovered, use the code with abnormal findings (Z00.01 for adults or Z00.121 for children) as the primary diagnosis. List each abnormal finding as a secondary diagnosis code. Document clearly what was found and any follow-up planned.
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