Case Assignment: Abnormal Findings

Case Assignment: Abnormal Findings

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Using a friend, family member, or colleague, perform a detailed men’s health history. Document the history and the expected normal physical examination findings in the SOAP note format. Even though your patient may have abnormal findings, you must document the expected normal exam findings for the system. If you would like to include the abnormal findings they should be noted in parenthesis next to the normal expected findings. The complete subjective and objective sections must be included. You may include the assessment and plan portion of the SOAP note, but these sections will not be graded. You should devise a chief complaint so that you may document the OLDCART (HPI) data. You must use the chief complaint of penile discharge, rectal bleeding, or frequent urination. You should also focus the ROS based on the patient’s chief complaint and the body systems being examined. Refer to the SOAP Note Format document in Course Resources as necessary. This will be the same format that faculty will follow during the immersion weekend. Please note the first post is due by Tuesday, 11:59 p.m. MT. During a routine exam, should a diagnosis or condition be discovered, it should be coded as an
additional code. Pre‐existing and chronic conditions and history codes may also be included as additional
codes as long as the examination is for administrative purposes and not focused on any particular
condition.
Some of the codes for routine health examinations distinguish between “with” and “without” abnormal
findings. Code assignment depends on the information that is known at the time the encounter is being
coded. For example, if no abnormal findings were found during the examination, but the encounter is
being coded before test results are back, it is acceptable to assign the code for “without abnormal
findings.” When assigning a code for “with abnormal findings,” additional code(s) should be assigned to
identify the specific abnormal finding(s).
Encounters for general medical examinations with abnormal findings
The subcategories for encounters for general medical examinations, Z00.0‐, provide codes for with and
without abnormal findings. Should a general medical examination result in an abnormal finding, the
code for general medical examination with abnormal finding should be assigned as the first‐listed
diagnosis. A secondary code for the abnormal finding should also be coded.
Our Coding for Pediatrics manual states that even a minor finding that may not be addressed with a
separate E/M service would merit reporting of Z00.121. Likewise a BMI that the physician considers
abnormal would support reporting of Z00.121 and the appropriate BMI code.
October 1, 2017
Based on this, any abnormality that is present at the time of the routine examination may lead to
reporting Z00.121 and a secondary code to describe the finding. This may include, but not limited to an
acute injury, an acute illness, an incidental or trivial finding that is diagnosed in the patient’s chart, an
abnormal screen, an abnormal exam finding (eg, scoliosis), a newly diagnosed chronic condition, or a
chronic condition that had to be addressed (excluding medication refill) due to an exacerbation or being
uncontrolled or new issues arising related to the chronic condition.
Do not report “with abnormal findings” for a chronic condition that is stabl