Wiki Billing labs related to the annual wellness visit with routine exam diagnoses Z00.00 or Z00.01

[sboroughs]

During an annual wellness exam, a provider ordered a lipid panel with a hyperlipidemia diagnosis instead of the routine exam diagnosis Z00.00/01 because the patient has hyperlipidemia. The labs were not reimbursed in the manner services related to the annual wellness exam would, the payer requested charge correction to the routine diagnosis codes in order to consider them as related to the patient's annual wellness benefit. As the patient presented for the annual wellness exam and not a check on their hyperlipidemia, are we able to code the lab based on the reason for the visit, or are we bound to using the hyperlipidemia diagnosis because the patient was previously diagnosed with it?

 

[mitchellde]

The labs were performed because the patient has hyperlipidemia. Most payers will not pay labs when they are submitted with the Z00 or Z01 codes, and it is not a screening.

 

[thomas7331]

I agree. The diagnosis should reflect the reason that the provider ordered the labs, as documented in the patient's records. But you may wish to review this payers written policies - if they have specific instructions as to how they wish certain services to be billed in certain situations, and you have that in writing, then you can follow those guidelines.

But I would not code a claim incorrectly just based on a verbal request and it is not up to the payer to tell a provider to change a patient's diagnosis. If they wish to pay the claim under the wellness benefit, then they are free to do that, but they should not be telling providers to put information on a claim that is not correct to enable them to pay something a certain way.