A patient came in for an annual visit and stated that she also needs paperwork completed to finalize an adoption. I am a bit confused on how to code this encounter for the following reasons: the sole purpose of the visit is to have a yearly physical and (2) have paperwork completed for adoption services (which is a mandated service). I chose Z00.00 for the primary code and Z02.82 for the secondary code and I did not append mod-32 to the 99396 since the progress note reads:

CC: Physical/Adoption paperwork

HPI: 33 year old female presents with c/o Annual physical exam. Feels well. She is finalizing an adoption next week. She denies sadness and is motivated. She has no special concerns. She is not on OCPs and has been married for 5 yrs.

I need to know if I am supposed to append the mod for a mandated service since the service was included in the encounter and if Z02.82 is appropriate for an adult who is seeking to adopt.

Your help is appreciated!

Thanks,
Trenisha- Future Certified Coder:confused: