Wiki Billing ills and wells together

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I believe there is some controversy on this. Our office is billing both for same visit and we are getting paid for it. I assume others are as well.

For those that are comfortable with this my question is how do you determine the level of e/m? Do you look at the components and kind of subtract out what would have been done for just a physical? And if you want to use time as the key factor would you just look at the time spent on the problem?

An example: Child has pain in ear. The provider spends an additional 15 minutes on the ears and of that 10 minutes discussing with mom what to watch for, how to treat, etc. so we would bill 99213.

Comments? Suggestions?
 
You really cannot bill out both together. It is not a matter of being comfortable with it and getting paid. It is a matter of compliant coding. The Z00 category states encounter for general exam without complaint, suspected or reported diagnosis. This means that if the child presents with symptoms then you cannot use the the codes in this category. And you cannot call presenting symptoms abnormal findings. I realize the exclude 1 note is currently under the Z00.0 subcategory, but the well child codes ar a part of the Z00 category. The category description applies to all codes in the subcategory. As a certified coder our responsibility is correct and compliant coding.
 
Cpt 2016

I understand how you're reading it in ICD-10 but I am waiting for something authoritative. The CPT 2016 still has instructions for billing ills and wells together.
 
These are two different systems. Just because CPT says one thing does not mean the dx rules will work with it. The guidelines and conventions in the ICD code book ARE the authoritative directives. These are conceived and written by the WHO in conjunction with the cooperative authorities.
 
Although it would be extremely tricky, I believe it is possible to bill both sick and well visits together. However, the one thing you must do as a coder is make sure that the documentation supports both. And what I mean by that is, you could extract the documentation for the sick visit and the remaining documentation would still contain the key components necessary to support the well visit and vice versa. There can be no sharing of documentation. Just because you CAN get paid for something doesn't mean you should get paid. That's a fine line between compliance and fraud.
 
Your still not looking at the diagnosis issue. While you might have the documentation, while CPT still indicates that you can submit a preventive level with an office visit level, you will not have a diagnosis to attach to the office visit due to ICD-10 CM rules with the category description and the exclude 1 exclusion; unless there is an abnormal finding with an asymptomatic patient.
 
Current AAP coding newsletter

Debra, check out the newsletter if you have access to it. There are specific examples of billing ills and wells together. It appears to be quite acceptable.
 
I understand that some find this acceptable and have written articles.m what I am pointing out is that for compliant coding and following correct coding guidelines and conventions, which we are suppose to adhere to as certified coders, the ICD-10 CM codes category descriptions and exclude 1 note does not allow to bill a symptomatic encounter at the same time as an asymptomatic encounter.
 
You can bill both together. Remember these things...documentation for each should be separate. In other words, you should have a note for the well and a note for the ill. No element of the well should be used when determining the level of the ill.
 
I will keep drawing attention to the ICD-10CM rules. The code category description is part of each code in the category. The category description for Z00 and Z01 codes states without complaint, suspected or reported diagnosis. The exclude 1 note states exclude 1 encounter for signs and symptoms- code to the signs and symptoms. It does not matter that some are being paid the code book clearly indicates that a patient that presents with symptoms/complaints, cannot be coded as a well patient. If you cannot code the diagnosis then you hav no diagnosis to link to the visit for the preventive or to the visit level. Why is it that this instruction is being overlooked?
 
mitchellde said:
I will keep drawing attention to the ICD-10CM rules. The code category description is part of each code in the category. The category description for Z00 and Z01 codes states without complaint, suspected or reported diagnosis. The exclude 1 note states exclude 1 encounter for signs and symptoms- code to the signs and symptoms. It does not matter that some are being paid the code book clearly indicates that a patient that presents with symptoms/complaints, cannot be coded as a well patient. If you cannot code the diagnosis then you hav no diagnosis to link to the visit for the preventive or to the visit level. Why is it that this instruction is being overlooked?
Click to expand...

Physician services are not reported as a single encounter. A separate diagnosis code may be assigned to each service line. The Z00 code is applicable only to the preventive medicine services provided while another diagnosis code representing the reason for service is appended to the problem-oriented visit. CMS, who collaborated with AHIMA and AHA on their ICD-10-CM educational series, recommends reporting both the routine health exam and code for a problem (existing or new) addressed at a single encounter. There is an example in the presentation for family physicians https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10ClinicalConceptsFamilyPractice1.pdf
 
That is not correct exactly. The exclude 1 edit is not diagnosis linking issue, it is a field 21 issue. When the ICD-10 CM instructions apply to diagnosis issues it applies to how they are listed in field 21, not how they are linked in field 24. Also again the category description applies to each code in the category. The category description clearly states "without complaint". It does not matter what any other presentation states, or any other coder or payer states. What matters is that when he WHO created the ICD-10 CM code set they applied this category description as well as the exclude 1 edit. Until or if they change this it is the intent of the ICD-10 CM code system that a symptomatic complaint cannot be coded with a preventive encounter. Our jobs as certified coders is to examine the rules and apply them as written. We may not deviate from them.
 
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