There is no ICD-10-CM code for a good faith exam. The code describes why the patient came and what the examiner found. A purely aesthetic visit is commonly coded Z41.1, whose inclusion terms cover a cosmetic procedure. A weight-management exam is an E66 code with a Z68 BMI code. When the treatment addresses a medical condition, such as focal hyperhidrosis, you code that condition.
The code comes from the examiner’s finding
The phrase “good faith exam” appears nowhere in the FY2027 ICD-10-CM index or tabular list. The exam is a clinical encounter, and it is coded like one: by the reason for the visit and the finding.
The official guidelines put the weight on the examiner. Section I.A.19 says code assignment “is based on the provider’s diagnostic statement that the condition exists.” For office visits, Section IV.H says not to code a diagnosis documented as “probable,” “suspected,” or “rule out,” and to code “to the highest degree of certainty for that encounter.”
That is the problem with a code printed on every intake form. If your template assigns E66.9 to every weight-loss patient, the chart now states a diagnosis the physician may never have made. A code is a statement of fact about one patient on one date. It has to come from the assessment the physician wrote.
The live good faith exams page covers who may perform the exam in each state. This post covers what the exam produces on paper.
Codes you will actually see in a cash-pay clinic
All descriptors below are quoted from the FY2027 ICD-10-CM, which took effect October 1, 2026. Each code was also checked in the FY2026 edition, and the descriptors did not change.
| Code | Official descriptor | When it fits | When it does not |
|---|---|---|---|
| Z41.1 | Encounter for cosmetic surgery | Aesthetic visit with no disease being treated. Inclusion terms list “Encounter for cosmetic procedure” | Reconstruction after a medical procedure or healed injury (Excludes1, Z42.-) |
| L74.510 to L74.519 | Primary focal hyperhidrosis, by site (axilla, face, palms, soles, unspecified) | The exam documents focal sweating and the toxin treats it | The visit is cosmetic and sweating is not the complaint |
| G24.5 | Blepharospasm | The examiner diagnoses it | Brow or crow’s feet lines treated for appearance |
| E66.3 | Overweight | Provider documents overweight | BMI alone, without the provider’s diagnosis |
| E66.811, E66.812, E66.813 | Obesity, class 1, class 2, class 3 | Provider documents obesity and its class | Class not documented (E66.9, Obesity, unspecified) |
| Z68.25 to Z68.45 | Body mass index [BMI], adult, by range | Secondary code, alongside an associated diagnosis | Alone, or during pregnancy |
| Z71.3 | Dietary counseling and surveillance | Counseling documented at the visit | As a substitute for the condition code |
| Z53.09 | Procedure and treatment not carried out because of other contraindication | The exam found a contraindication and the treatment was not given | The patient simply changed their mind (other Z53 codes) |
As of October 2026. ICD-10-CM updates every October 1, and some codes also change April 1.
Weight management has two rules most charts miss
The E66 category carries a note: use an additional code to identify BMI, if known, from Z68. The Z68 guideline adds the limit. BMI codes “should only be assigned when there is an associated, reportable diagnosis (such as obesity or anorexia) documented by the patient’s provider.” They are not assigned in pregnancy.
Section I.B.14 lets a nurse or dietitian record the BMI number, but the associated diagnosis “must be documented by the patient’s provider.” BMI codes are reported only as secondary diagnoses.
For your weight-management program, that means the scale reading taken at intake supports a code only after the physician writes the diagnosis it relates to. A patient with a BMI in the overweight range and no documented diagnosis gets no E66 code from the template. If the physician documents overweight, E66.3 goes first and the Z68 range follows.
The same drug can be two different encounters
Neurotoxin for glabellar lines is cosmetic. Neurotoxin for primary axillary hyperhidrosis treats a medical condition. Same vial, different finding, different code, and a different coverage answer.
Medicare excludes “cosmetic surgery and related services, except as required for the prompt repair of accidental injury or to improve the functioning of a malformed body member” (42 CFR 411.15(h)). The Medicare Benefit Policy Manual defines cosmetic surgery as “any surgical procedure directed at improving appearance,” and keeps coverage for surgery “for therapeutic purposes which coincidentally also serves some cosmetic purpose” (Chapter 16, Section 120). Private plans set their own terms, so read the plan.
The Botox and filler exam post covers what the examiner screens for. If that screen turns up a medical condition, the chart has to say so in the assessment, and the code follows the assessment. Do not reclassify a cosmetic visit as medical to make it billable. The code describes what happened.
CPT: there is no separate good faith exam code
CMS’s E/M guide (MLN006764, May 2026) describes no separate code for a good faith exam. If you ever bill one to a payer, it is an office or outpatient evaluation and management visit. CMS lists those codes as 99202 to 99205 and 99211 to 99215, and it sorts patients into new and established by whether they received professional services from the same physician, or one of the same specialty in the same group, within the previous three years. CPT descriptors are AMA copyrighted and we do not reproduce them here.
The level of an E/M visit depends on what was documented. Anything you send to a payer goes through a certified coder first. Treat this post as coding information, not coding or legal advice.
What the chart shows regardless of the code
In a cash-pay clinic the code may never leave the building. It still shows up on lab requisitions, on a superbill a patient requests, and in any board or payer review of the record. The chart has to carry the reasoning behind it:
- Who examined the patient, with license type, and where the patient was located.
- History, medications and allergies reviewed.
- The finding, written as an assessment by the examiner.
- The treatment considered and the contraindications checked.
- The decision: approved, approved with limits, or declined.
- The diagnosis code that matches item 3, entered after the assessment, not before.
The documentation post walks through what boards in Washington, Texas and Florida expect to see.
What this means for you
Remove pre-filled diagnosis codes from your intake templates. Let the examining physician write the assessment and pick the code from it: Z41.1 for a cosmetic visit, E66 with Z68 when the physician documents overweight or obesity, the specific condition when the treatment is medical. Audit ten charts and check that each code matches the written finding. If any visit is billed to insurance, route it through a certified coder. MDside supplies the physicians who perform and document these exams for med spas and weight-management programs.
Related reading
Frequently asked questions
What is the ICD-10 code for a good faith exam?
There is none. The phrase does not appear in the ICD-10-CM index or tabular list. The code reflects the reason for the visit and the examiner’s finding. A purely aesthetic visit is commonly Z41.1, Encounter for cosmetic surgery, whose inclusion terms cover a cosmetic procedure. A weight-management visit uses an E66 code with a Z68 BMI code when the provider documents the diagnosis.
Is there a CPT code for a good faith exam?
CMS’s E/M guide describes no separate code for it. If the exam is billed to a payer, it is reported as an office or outpatient E/M visit, which CMS lists as 99202 to 99205 and 99211 to 99215. The level depends on the documentation. Have a certified coder review any visit you submit to insurance.
Can I code Z68 BMI without an obesity diagnosis?
No. The official guideline says BMI codes should only be assigned when there is an associated, reportable diagnosis, such as obesity, documented by the patient’s provider. A nurse may record the BMI number, but the physician must document the diagnosis. BMI codes are secondary only and are not assigned during pregnancy.
Does Medicare cover a cosmetic good faith exam?
Medicare excludes cosmetic surgery and related services under 42 CFR 411.15(h), except for prompt repair of accidental injury or to improve the functioning of a malformed body member. An exam for a purely cosmetic treatment generally falls on the excluded side. An exam that diagnoses and treats a medical condition, such as focal hyperhidrosis, is a different encounter.
This is coding information, not coding or legal advice. Confirm codes for any insurance-billed visit with a certified coder. This is general information, not legal advice. Rules vary by state and change. Confirm your own facts with counsel.