Coding chronic conditions with preventive well-checks

Radcoder86

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The ICD-10 CM code categories for the general preventive state "without complaint, suspected , or reported diagnosis". So no I would not code any of the chronic conditions as I consider those to be the other rooted diagnosis. And if the patient presents with a complaint the you cannot perform the wellness on the same day.
This was the post making me think we can't code an E/M with a PE. Maybe it will just end up being payor specific and will depend on how they interpret the guidelines.
 

mitchellde

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If the code states excludes 1 then it is not payer specific it is a code directive that you cannot code them together.
 

mitchellde

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My original question was regarding ICD codes and when it is appropriate to code chronic conditions or additional diagnoses with well checks.

The debate has been whether or not you can code a well check code (Z00-) with a diagnosis code (and attach both to the well visit 99395). The ICD 10 book states an excludes 1 note under Z00- saying, "encounter for examination of sign or symptom- code to sign or symptom." An adult or child that presents to his/her primary care physician for a well-check is not presenting for an encounter for examination of sign or symptom. If the patient happens to bring up a complaint during the exam, then this complaint should be treated as an additional e/m with the well visit.

Of course, not all physicians will document enough to warrant an e/m. The coding guidelines state that chronic conditions or additional diagnoses found upon examination of a patient during a routine health exam can be coded as secondary diagnoses.

Chapter 21 of the ICD 10 book states that nonspecific abnormal findings are coded using R70-R94. The Z00- codes do not use the term "nonspecific" (such as Z00.01 encounter for general adult medical examination with abnormal findings), so, any other abnormal findings such as a specific diagnosis like headache can be coded in addition to the Z00.01 code.

Of course, this is my interpretation of the rules and I realize not everyone agrees. I appreciate all of the feedback and would love to hear more!!!!! I wish this was more clear. :)

I've been re-reading the ICD-10 book over this for the past couple of days, along with the other coders in my office...this has been quite confusing!

I work in pediatrics, so I submitted my concern to the AAP and they provided me documents stating that yes, you can code chronic conditions and diangoses found upon examination of the patient in addition to the well check Z00.121.
A complaint of a headache is not an abnormal finding nor is a presenting symptom of a cough. Those are signs and symptoms that will be addressed and reschedule the wellness. An abnormal finding is something discovered by the provider in an otherwise a symptomatic patient.
 
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A complaint of a headache is not an abnormal finding nor is a presenting symptom of a cough. Those are signs and symptoms that will be addressed and reschedule the wellness. An abnormal finding is something discovered by the provider in an otherwise a symptomatic patient.
Understandable - the physician should bill a well check with an e/m for the headache like they can and do now.

There is no way providers are going to reschedule a well-check just because the patient happens to say during the well-check, "oh by the way, I have been having headaches, what should I do about this?" That warrants billing an additional e/m.

For a condition found upon routine well-check, like impacted cerumen, the AAP states that this diagnosis can be coded along with Z00.121. The terms noted in Chapter 21 (nonspecific abnormal findings vs. abnormal findings) are confusing and that's where I'm not seeing eye-to-eye :(
 

mitchellde

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You can code the diagnosis - attach it to the e/m CPT and not with the well-check CPT. Then the diagnosis code would not be in any relation with the Z00- code - like what Radcoder just said.
You cannot code the symptom with the Z00 in field 21. The exclude 1 note means these codes cannot be coded together. This not a linkage issue.
 

mitchellde

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Understandable - the physician should bill a well check with an e/m for the headache like they can and do now.

There is no way providers are going to reschedule a well-check just because the patient happens to say during the well-check, "oh by the way, I have been having headaches, what should I do about this?" That warrants billing an additional e/m.

For a condition found upon routine well-check, like impacted cerumen, the AAP states that this diagnosis can be coded along with Z00.121. The terms noted in Chapter 21 (nonspecific abnormal findings vs. abnormal findings) are confusing and that's where I'm not seeing eye-to-eye :(
Sorry but the exclude 1 note will not allow using a presenting headache with the wellness
 
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Sorry but the exclude 1 note will not allow using a presenting headache with the wellness
Well - with the pediatric codes, that excludes note does not apply. So, maybe it is just for the adult health examinations. Maybe that is why AAP says you can code additional signs/symptoms/diagnoses with the pediatric Z00.121.

I'm left wondering how CPT would handle this...can't code 99395 with 99213 anymore? Because there would be an additional diagnosis with the Z00- code. It just doesn't make sense. Does anyone else find this odd?? :confused:
 

mitchellde

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Well - with the pediatric codes, that excludes note does not apply. So, maybe it is just for the adult health examinations. Maybe that is why AAP says you can code additional signs/symptoms/diagnoses with the pediatric Z00.121.

I'm left wondering how CPT would handle this...can't code 99395 with 99213 anymore? Because there would be an additional diagnosis with the Z00- code. It just doesn't make sense. Does anyone else find this odd?? :confused:
While the exclude one note may not be repeated for the well child sub categories they are still a part of the Z00 category with dates encounter for general exam WITHOUT complaint , suspected, or reported diagnosis
 
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pedscoder21,
I too would love the AAP information you recieved. I am a Pediatric coder also and have typically billed for Preventive and Office Visit charges on the same day prior to 10/01. My practice is associated with a Medical Univerisity and Children's Hospital with a significant percentage of patients being chronicly troubled w/ large range of medical issues. Many are not "Well" at their preventive visits. There Patients typically require allot of time over and above a standard preventive visit. There should be allowances for that ( in my opinion anyway). email address below.

lgriffin2@gru.edu
 

Radcoder86

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Okay Debra, so if someone comes in for wellness and they have hyperlipidemia as a chronic condition, but in the note it states that their LDL has risen significantly (reviewing labs for wellness), do I code that as abnormal findings?
 

Rfoster

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would like AAPC info emailed also

pedscoder21,
If you'd be so kind to forward that info to me as well I would greatly appreciate it. I also am a pediatric coder and this is a scenario we seem often. I've told our provider the new "rules" of split billing but there are still
a lot of questions we are having . Can you please forward your info from AAPC to RBoswell@intpeds.com.
Please and thank you so much!
Rachel
 

mitchellde

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Okay Debra, so if someone comes in for wellness and they have hyperlipidemia as a chronic condition, but in the note it states that their LDL has risen significantly (reviewing labs for wellness), do I code that as abnormal findings?
Yes if documented by the provider as a finding requiring attention.
 
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http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_049298.hcsp?dDocName=bok1_049298

This AHIMA article states that additional diagnosis codes are allowed with the Z00- codes (so long as the intent of the encounter was for a routine exam, not for a symptom/diagnosis/etc). Example that they give:

"45-year-old established patient presented to her physician's office for a routine physical exam. During the examination the physician identified an enlarged thyroid. The physician ordered a laboratory test and requested to see the patient in two weeks."

First listed dx: Z00.01 - encounter for general adult medical examination with abnormal findings
Additional dx: 240.9 - goiter, unspecified
 
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Thanks again for your input Debra, this has been a confusing topic ;)

I posted that article to share some additional info out there on coding well-checks.
 

tcan618

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Hello, I have a question. We have a patient that came in for a scheduled routine exam, but he/she also has 3 or so chronic dx's that were addressed during this visit. The doctor documented dx's were unchanged, or unchanged with medication changes. The doctor is billing for both a preventive exam w/dx z00.00 and also a 99214 w/medical dxs.
This is a medicare pt, so after he did the Medicare AW exam, he continued to do the entire ROS and Exam. Any thoughts on this??? Thank you!
 

thelton

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There is an article in the October 12, 2015 Part B News that addresses the problem visit with a preventive visit. Basically, it states that you can still bill a problem visit on the same day as a preventive visit.
 

D.I.

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--------------------------------------------------------------------------------

I submitted my question to the AAP this morning and they responded with some very helpful documents with examples (obviously, they are related to pediatrics). These examples include coding the pediatric Z codes with diagnoses found upon examination. If anyone would like a copy of them, please post your email and I will forward
__________________


I code for a multi-specialty clinic with Pediatrics as a specialty. Could you please send me the information as well?? ladonnaimparato@yahoo.com

Thank you in advance!
Donna, CPC, AAS
 

mitchellde

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There is an article in the October 12, 2015 Part B News that addresses the problem visit with a preventive visit. Basically, it states that you can still bill a problem visit on the same day as a preventive visit.
Only if it is an abnormal finding. You cannot bill a presenting sign or symptom at the same time as the wellness. The ICD10 CM conventions are really very clear on this. It is an exclude 1 convention and the Catergory descrption clearly states without complaint. A presenting complaint is not an abnormal finding.
 

jbuelto

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Received this as part of the questions coming up since the icd 10 switch..
?Don?t overthink the changes
?Many CPT coding questions have come up as a result of the change
?CPT coding and reimbursement policies based on CPT remain the same
?Focus on the basics: location, laterality, clinical details
General medical exam
?The CPT rules are not changed with the implementation of ICD-10. The rules for billing a ?sick visit? on the same day as a ?preventive visit? require:
?Significant and separately identifiable services (documentation of the sick visit) was performed on the same day as the physical. If both are 1) medically necessary and 2) documented separately, no ?double dipping,? then add Modifier -25 to the Evaluation and Management Code (reporting the ?sick visit? with 99201-99205 or 99211-99215).

I think the wording was confusing...but in Leigh-mans terms:
excludes 1: Encounter for EXAMINATION of signs and symptoms code to signs and symptoms... so if you are examining a patient for signs or symptoms use the 99201-99215 codes.. which would be separate and identifiable from the well visit...
 

mitchellde

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Received this as part of the questions coming up since the icd 10 switch..
?Don?t overthink the changes
?Many CPT coding questions have come up as a result of the change
?CPT coding and reimbursement policies based on CPT remain the same
?Focus on the basics: location, laterality, clinical details
General medical exam
?The CPT rules are not changed with the implementation of ICD-10. The rules for billing a ?sick visit? on the same day as a ?preventive visit? require:
?Significant and separately identifiable services (documentation of the sick visit) was performed on the same day as the physical. If both are 1) medically necessary and 2) documented separately, no ?double dipping,? then add Modifier -25 to the Evaluation and Management Code (reporting the ?sick visit? with 99201-99205 or 99211-99215).

I think the wording was confusing...but in Leigh-mans terms:
excludes 1: Encounter for EXAMINATION of signs and symptoms code to signs and symptoms... so if you are examining a patient for signs or symptoms use the 99201-99215 codes.. which would be separate and identifiable from the well visit...
The excludes 1 note means you cannot code them together. You cannot code the Z00.00 with a symptom. The category Z00 states without complaint. You really cannot justify a sick patient presenting for symptoms and a well visit. This has nothing to do with the use of the 25 modifier. It is the diagnosis codes category definition and the exclude1 definition. CPT rules and usage instruction cannot address this issue.
 

jbuelto

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I see this post growing so I just shared what I received in a follow up icd 10 questionaire...

excludes 1: Encounter for EXAMINATION of signs and symptoms --"code to signs and symptoms" perhaps if ONLY was there I would agree with you...

So technically yes, you are right.. Z00.00 will go with 9939* and separately my knee pain which was discussed in detail with an xray ordered can go to a 99213-25...they are not together, they are separate...
 

anne32

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The general guidelines do not even support what you are saying in your post. The general guidelines say "The codes are not to be used if the examination is for diagnosis of a suspected condition or for treatment purposes. In such cases, the diagnosis is used." I understand you are saying the codes are separate- the Z code is for the physical and then the problem is with an E/M. The general guidelines go on to say "Pre-existing and chronic conditions and history codes may also be included as additional codes as long as the examination is for administrative purposes and not focused on any particular condition." So basically certain other codes can be added as long as the exam is not focused on treating the condition or a main focus of the exam.
 

jbuelto

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Payments are based on CPT codes, So are you saying they are wrong in providing information stating otherwise? I'm just asking so that I can make them aware of their error...

Thank you!
 

jbuelto

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The general guidelines do not even support what you are saying in your post. The general guidelines say "The codes are not to be used if the examination is for diagnosis of a suspected condition or for treatment purposes. In such cases, the diagnosis is used." I understand you are saying the codes are separate- the Z code is for the physical and then the problem is with an E/M. The general guidelines go on to say "Pre-existing and chronic conditions and history codes may also be included as additional codes as long as the examination is for administrative purposes and not focused on any particular condition." So basically certain other codes can be added as long as the exam is not focused on treating the condition or a main focus of the exam.
and these guidelines are not new.. they also applied to ICD 9 guidelines which is why it's makes it all the more confusing...
 

mitchellde

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The excludes 1 note does not mean that you link the codes to separate encounters, it means they cannot be coded together. That means at the same encounter. Just because CPT rules state it is acceptable to code a preventive with an office visit as long as you use a 25 modifier, does not mean you can over ride ICD-10 conventions in order to get it done.
This has been one of the most difficult concepts to get across, but it is an ICD-10 CM issue and it does change things.
 

thelton

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There is an article in the October 12, 2015 Part B News which addresses the issue of a problem visit billed on the same day as a preventive service which states you can bill both visits. There are several industry experts quoted in the article and they helped clear up any confusion in my mind about this issue.
 
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There is an article in the October 12, 2015 Part B News which addresses the issue of a problem visit billed on the same day as a preventive service which states you can bill both visits. There are several industry experts quoted in the article and they helped clear up any confusion in my mind about this issue.
I wish I had access to this but our office doesn't have a subscription :( is there any other way to get access to these articles? (I'm guessing not).
 

mitchellde

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No there is no way to acess these without a subscription, but they are very careful in the wording. It does not state that you can bill a symptomatic patient with a well visit. It only addresses the issue of billing a preventive CPT code with an office visit. CPT instruction do state you can do this. However at no time does the article state that you can bill a symptomatic diagnosis with a visit for preventive.
 

thelton

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I respectively disagree with the above statement. The Part B News article quotes at least 3 industry experts who state the excludes note does not exclude billing a problem visit on the same day as a preventive visit. The title of the article is "ICD-10 Z-codes don't mean you can't bill preventive, problem services together". That seems pretty straightforward to me.
 

mitchellde

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I am not seeing how they say that ; the excludes 1 note says encounters forsigns and symptoms are purely excluded, and that is what a problem visit is. So you are saying we are to ignor the ICD-10 CM conventions and just code what you want. Then where does it end? At what point do the rules/guidelines/conventions mean anything? I will continue to voice my objections to this line of thinking and state that the excludes 1 is extremely clear in this and you cannot code them together.
 

mitchellde

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The article is about the proper use of a 25 modifier and the writer used a bad and incorrect example. I am going to contact the AAPC regarding this error.
 

JDELINA

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--------------------------------------------------------------------------------

I submitted my question to the AAP this morning and they responded with some very helpful documents with examples (obviously, they are related to pediatrics). These examples include coding the pediatric Z codes with diagnoses found upon examination. If anyone would like a copy of them, please post your email and I will forward
__________________


I code for a multi-specialty clinic with Pediatrics as a specialty. Could you please send me the information as well?? ladonnaimparato@yahoo.com

Thank you in advance!
Donna, CPC, AAS
can you send me a copy too....pls e mail to vchc4117@yahoo.com
 

ollielooya

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Debra, have you yet received a reply to your question to AAPC about the example furnished in Healthcare Business Monthly? I've been waiting to be bombarded from our physicians with the questions similar to the one that started this thread, and it happened today. I'm preparing a response, but have realized that this will continue to be a mis-understood topic and interpreted and misinterpreted in various ways. I think I understand it now, but only after much study and musing on my part. My old brain has been having difficulty emerging from the maze and haze! It just seems easy to inform the physicians that rescheduling the patient for their preventive visit separate from the problem-focused visit would be the way to go, albeit not a popular solution for the patient in regards to convenience. Also this issue that this thread addresses is just another reason why administrative billing/coding folk can't assume that just because "this is the way we've always done it" would be applicable to what's being required now!
Anyway, eager to see your continued input to this thread and what you hear from AAPC.
 

CodingKing

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Let's pretend you can still bill both. The key word is significant. Thinking of my own annual physicals and seeing some appeals from patients who feel their physician is inappropriately billing both. 90% of the time the definition of significant is not met. Just because you address a preexisting medical condition does not mean the work done to address it was significantly over and above what is included in a preventive visit.
 

ollielooya

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True, when we're dealing with the use of Modifier 25. If "significant" the issue addressed would have to be able to stand alone based on the chart notes. I know if this is brought up during one of our chapter coding meetings, it will be a "hot" topic and the arguments will ensue based on what we've already read here. I'm taking the conservative approach here and advising our doctors to shore up their policies on this to their patients and if possible to schedule the preventives separate from the EM problem focussed visits.
 

Gnunez

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I submitted my question to the AAP this morning and they responded with some very helpful documents with examples (obviously, they are related to pediatrics). These examples include coding the pediatric Z codes with diagnoses found upon examination. If anyone would like a copy of them, please post your email and I will forward ;)
gnunez1971.gn@gmail.com
 
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