HCC Diagnoses on Preventive Visits (Z00.00) – Claim Submission and Acceptance Question

[briana.lindsey]

I'm looking for feedback from anyone who has experience with risk adjustment/HCC reporting and preventive visit claim submission requirements.

We are reviewing situations where a provider documents and supports a chronic condition (meeting MEAT criteria), and the diagnosis is present in the medical record, but the diagnosis does not appear on the final professional claim after charge capture review.

One area we are investigating involves preventive visits billed with Z00.00 (Encounter for general adult medical examination without abnormal findings).

My questions are:

1. If a claim includes a valid HCC diagnosis along with Z00.00, is that generally sufficient for the diagnosis to be accepted and submitted for risk adjustment purposes?
2. Do payers typically require the diagnosis to be linked to a separately billable charge line and/or a CPT II code for the diagnosis to be accepted on the claim?
3. Have you seen payer-specific requirements where chronic conditions documented during a preventive visit are removed or not submitted when only Z00.00 is billed?
4. Are there specific CMS, Medicare Advantage, or commercial payer guidelines that address this scenario?

We are trying to better understand whether the issue is related to claim-edit rules, coding guidelines, payer requirements, or billing workflow processes before pursuing provider education or workflow changes.

I would appreciate any insights, payer-specific experiences, references, or best practices others have encountered.

 

[rthomas@impcna.com]

I'm looking for feedback from anyone who has experience with risk adjustment/HCC reporting and preventive visit claim submission requirements.

We are reviewing situations where a provider documents and supports a chronic condition (meeting MEAT criteria), and the diagnosis is present in the medical record, but the diagnosis does not appear on the final professional claim after charge capture review.

One area we are investigating involves preventive visits billed with Z00.00 (Encounter for general adult medical examination without abnormal findings).

My questions are:

1. If a claim includes a valid HCC diagnosis along with Z00.00, is that generally sufficient for the diagnosis to be accepted and submitted for risk adjustment purposes?
2. Do payers typically require the diagnosis to be linked to a separately billable charge line and/or a CPT II code for the diagnosis to be accepted on the claim?
3. Have you seen payer-specific requirements where chronic conditions documented during a preventive visit are removed or not submitted when only Z00.00 is billed?
4. Are there specific CMS, Medicare Advantage, or commercial payer guidelines that address this scenario?

We are trying to better understand whether the issue is related to claim-edit rules, coding guidelines, payer requirements, or billing workflow processes before pursuing provider education or workflow changes.

I would appreciate any insights, payer-specific experiences, references, or best practices others have encountered.

1. Yes, you can include an HCC dx with Z00.00, and it counts for risk adjustment reporting. Wellness exams are the best time to capture your HCC codes, especially if it's an AWV.
2. No, HCC codes do not need to be associated with a CPT II code. If there are more than 12 dx, adding a CPT II code would help report the codes in the same encounter.
3. I have never seen a payer remove chronic diagnoses when billed with Z00.00. 99% of the time, when a patient comes in for a wellness visit, there is another problem addressed, such as their chronic conditions.
4. It would be best to check with your local MAC and payers regarding these guidelines.

I currently code and bill for an Internal Medicine & Pediatric office and we use HCC codes and other dx with AWV & wellness exams frequently as long as the provider has documentation other than just HTN stable.

This link might be helpful: https://snapehealth.com/post/maximi...des-during-the-medicare-annual-wellness-visit