Z00.00 - Encounter for general adult medical examination without abnormal findings

Clinical Definition

Acute appendicitis is inflammation of the appendix requiring surgical intervention, characterized by sudden onset of right lower quadrant pain with characteristic migration from periumbilical area.

Documentation Requirements

• Acuity (acute vs chronic)

• Anatomical location confirmation (appendix)

• Associated complications if present:

  • Perforation status

  • Presence/absence of peritonitis

  • Presence/absence of abscess

• Surgical findings during appendectomy

• Any pre-existing conditions affecting treatment

• Method of diagnosis (CT, ultrasound, clinical)

Common Synonyms

• Inflamed appendix

• Appendix infection

• "Pain in right lower belly"

• "McBurney's point pain"

Coding Conflicts

Excludes1:

• Appendicitis with generalized peritonitis

• Appendicitis with peritoneal abscess

Excludes2:

• Appendicular colic (without inflammation)

• Chronic appendicitis

Scribing.io Automation

The AI scribe automatically identifies:

• Pain location descriptors ("RLQ", "periumbilical")

• Migration patterns of pain

• Rebound tenderness documentation

• Diagnostic imaging results

• Lab values (WBC count, CRP)

• Surgical findings keywords

• Complication terminology

For accurate coding, the AI highlights missing elements and prompts for specific documentation gaps in real-time.