Preventive medicine evaluation and management (E/M) service is a foundation of pediatric primary care. Code assignment for these services involves codes that designate whether the patient is new or established and the age of the patient at the time of service. Table 1 provides a reference for the preventive medicine E/M procedure codes with corresponding diagnosis codes. Time is not a factor in determining the code for preventive E/M services.

For the purpose of assigning diagnosis codes for preventive E/M services, an abnormal finding is a newly discovered condition on a screen or a known or chronic condition that requires attention (eg, uncontrolled, acutely exacerbated). Assign additional codes for any abnormal findings in addition to Z00.121 or Z00.01. A stable chronic condition is not considered an abnormal finding, but a code for the condition is reported in addition to code Z00.129 or Z00.00, when addressed.

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