Wiki Coding a sick EM with a CPE

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amexnikki23

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Our office has been going back and forth on the coding of sick visits along with CPE for some time now. While we've finally come to the agreement that our providers generally should NOT charging an EM for conditions found on exam or lab results, we cannot seem to agree on the rationale for coding a sick EM service just because the patient has a chronic illness that needs refilling of prescriptions or even labs ordered as the result of that established chronic condition maybe being deemed to be worsening. Example below:

Patient is seen for annual CPE. Has 2 chronic conditions: hyperlipidemia and hypertension.
HPI states "patient here for CPE and although has hyperlipidemia and hypertension, states is doing well w/no complaints."
Provider does full exam as part of the CPE and then orders a refill of 2 medications that the patient is already on for his 2 chronic conditions.

Provider charged for a CPE, as well as a 99213. Your thoughts?
 
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No this should not be done. Visit and medical services are provided at the request of the patient. With no complaints or concerns the patient has not requested an additional encounter. For the provider to go over chronic conditions and renew meds is an expected component of the annual. Come Oct 1 this is a moot point as you cannot use additional dx codes with the preventive dx code, except for abnormal findings upon exam. Also the affordable care act indicates that when the primary purpose of the encounter is preventive you may not have a separate level with a co pay.
 
According to instructions in CPT, if an abnormality is encountered or a preexisting problem is addressed in the process of performing a preventive medicine evaluation, and if the problem is significant enough to perform the key components of a problem-oriented visit, then the appropriate office/outpatient code should be reported in addition to the preventive. This happens often and is very much billable scenario according to AMA CPT guidelines. If there is written references to the contrary, I would ask to see that information.
 
mitchellde said:
No this should not be done. Visit and medical services are provided at the request of the patient. With no complaints or concerns the patient has not requested an additional encounter. For the provider to go over chronic conditions and renew meds is an expected component of the annual. Come Oct 1 this is a moot point as you cannot use additional dx codes with the preventive dx code, except for abnormal findings upon exam. Also the affordable care act indicates that when the primary purpose of the encounter is preventive you may not have a separate level with a co pay.
Click to expand...

Debra, with all due respect (and I have much respect for you after seeing your posts on this site for a few years now), I don't believe this is true. I have found nothing that says you won't be able to bill a well and a sick visit at the same time with ICD-10. In fact, AAPC has an article which states that ICD-10 will make this easier to do:

http://news.aapc.com/there-is-a-bright-side-to-icd-10-cm/

Also, the ICD-10 guidelines for the Z00.01 state that "additional code(s) should be assigned to identify the specified abnormal finding(s)."

It says nothing about not being able to assign additional codes to an acute E/M visit.

Looking at the affordable care acts rule about no copay for a preventive visit, it seems to be just that you cannot be charged a copay "for the preventive visit" itself; it says nothing about not being allowed to charge an additional office visit, if valid and necessary. in fact, more than one article I've read makes it clear that a patient could be charged a copay if something non-preventive was done during a preventive visit.

if you can provide a clear source that states this will be unbillable after October 1st, I'd really like to see it so I can present it to my office.

thanks

Again, I really do have a lot of respect for you and you knowledge in this field. :)
I think this is the first time I've disagreed with something you've posted. :eek:
 
Additional information from ICD10 Coding Guidelines Section I.C.21, under "Routine and Administrative Examinations." It states: "The Z codes allow for the description of encounters for routine examinations, such as general check-up....During a routine exam, should a diagnosis or condition be discovered, it should be coded as an additional code."
 
It says with abnormal findings, not presenting patient complaints. These are two very different scenarios. If the patient presents for a scheduled wellness encounter and expresses symptoms, ICD-10 CM has an excludes1 note for this look aunt the Z00.0 subcategory and the Z01category. It says excludes 1 signs and symptoms. Excludes 1 means they cannot be coded together and the note goes further to instruct to code to the signs and symptoms. This means you cannot bill the symptoms expressed by the patient with the general wellness visit.
I did not say that you cannot bill abnormal findings with a preventive. However a patient that expresses a symptom or complaint is not an abnormal finding.
 
lgardner said:
Debra, with all due respect (and I have much respect for you after seeing your posts on this site for a few years now), I don't believe this is true. I have found nothing that says you won't be able to bill a well and a sick visit at the same time with ICD-10. In fact, AAPC has an article which states that ICD-10 will make this easier to do:

http://news.aapc.com/there-is-a-bright-side-to-icd-10-cm/

Also, the ICD-10 guidelines for the Z00.01 state that "additional code(s) should be assigned to identify the specified abnormal finding(s)."

It says nothing about not being able to assign additional codes to an acute E/M visit.

Looking at the affordable care acts rule about no copay for a preventive visit, it seems to be just that you cannot be charged a copay "for the preventive visit" itself; it says nothing about not being allowed to charge an additional office visit, if valid and necessary. in fact, more than one article I've read makes it clear that a patient could be charged a copay if something non-preventive was done during a preventive visit.

if you can provide a clear source that states this will be unbillable after October 1st, I'd really like to see it so I can present it to my office.

thanks

Again, I really do have a lot of respect for you and you knowledge in this field. :)
I think this is the first time I've disagreed with something you've posted. :eek:
Click to expand...
If you look at my response I state that you can if there is an abnormal finding which as I have indicated is very different from a patient that presents with symtoms and complaints. Again the exclude 1 note from the Z00.0 subcategory negates being able to code symtoms with the Z00.0 codes.
The affordable care act reads really convoluted but if you look it is there:
"plans cannot impose cost-sharing requirements, such as co-pays, coinsurance, or deductibles with respect to specified preventive services in which preventive services are billed separately. When these services are part of an office visit, the office visit may not have cost-sharing if the
primary reason for the visit is to receive preventive services."
So if the patient presents primarily for preventive with no complaints your office cannot impose a visit level with a copay. However if there are abnormal findings that is different and now the code will be specific to that.
But we are instructed to code to the signs and symptoms only if the patient presents for a wellness visit as a sick patient.

I did not intend to start a firestorm and controversy only to bring to light an aspect of ICD-10 CM that I know many have not read or understood.
 
"I did not intend to start a firestorm and controversy only to bring to light an aspect of ICD-10 CM that I know many have not read or understood."

I don't think that there is a firestorm...much less one that you started.
:)

it's just that I've seen you mention this before and I've been looking into it, because it just doesn't seem right. we are very careful to only bill an OV with a preventive visit if there is a true medical necessity and clearly separate documentation to support it.
 
I did not say you were incorrect either, just that the ICD-10 CM codes do not allow for symtoms and complaints to be coded with the general medical visit codes. Abnormal findings yes.
 
"So if the patient presents primarily for preventive with no complaints your office cannot impose a visit level with a copay. However if there are abnormal findings that is different and now the code will be specific to that."

OK, so when you all are referring to "coding" the abnormal findings, you are referring to diagnostic coding, correct? That means if a patient presents with no symptoms or complaints but hyperlipidemia is discovered, then we can add that hyperlipidemia as a secondary dx code after the V70.0 on the claim, and cannot charge a separate EM. As far as the charging of a separate EM, what I'm hearing from you is that if the patient presents with symptoms or complaint and they are addressed and documented properly, we can charge a separate EM, AND charge a copay.
 
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