How much documentation detail is needed to support adding codes Z71.3 (dietary counseling) and Z71.82 (exercise counseling) to a claim? Is it enough for the provider to simply state "counseled on diet and exercise" or do they need to elaborate on the discussion? The codes do risk adjust for our Medicaid patients, and the providers are clicking a check box to add the dx to the A/P, but with little to no detail in the note. Resources would be really helpful! TYIA!
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Question documentation support for counseling Z codes
- Thread starter arrana
- Start date
TThivierge
True Blue
Hi Arrana,
The providers need to document differ foods and or water for the pt to suggest eating, put on diet plan with timely meals. They need to combine this with the chronic illness if there is one. Chronic illness such as: Sleep DO G47, Neuropathy G60, Paralysis G81-G83, Obesity E66.01, G72.81 Critical illness myopathy, Cardiac problems, I21 to I50, E43, K21.9 GERD which all are risk adjusting codes and linked with HCC number. They need to describe suggestions, and hopefully weight and BMI% dx block Z68. Suggest exercising such as walking,free weights, gym machines or videos put dx Z71.82. Do they use the CPT 99401-99403 with minutes listed in documentation for end with dx Z71.3 If pt smoking while dieting need to add the smoking cessation code ,dx F17 with modifier 25 on Eval Mgmt codes. Smoking cessation with CPT 99404 to 99409 they must document discuss stop smoking & how many minutes in record for the day. Check out dx Z13.228 and Z13.21 encounter to check nutrition levels if given lab test.
Well hope helped you
Lady T
The providers need to document differ foods and or water for the pt to suggest eating, put on diet plan with timely meals. They need to combine this with the chronic illness if there is one. Chronic illness such as: Sleep DO G47, Neuropathy G60, Paralysis G81-G83, Obesity E66.01, G72.81 Critical illness myopathy, Cardiac problems, I21 to I50, E43, K21.9 GERD which all are risk adjusting codes and linked with HCC number. They need to describe suggestions, and hopefully weight and BMI% dx block Z68. Suggest exercising such as walking,free weights, gym machines or videos put dx Z71.82. Do they use the CPT 99401-99403 with minutes listed in documentation for end with dx Z71.3 If pt smoking while dieting need to add the smoking cessation code ,dx F17 with modifier 25 on Eval Mgmt codes. Smoking cessation with CPT 99404 to 99409 they must document discuss stop smoking & how many minutes in record for the day. Check out dx Z13.228 and Z13.21 encounter to check nutrition levels if given lab test.
Well hope helped you
Lady T
lgardner
Expert
I would, definitely, expect more details than "counseled on diet and exercise", in order to submit an additional CPT code for counseling.
However, if the Z codes are being submitted with the E/M and are NOT being used to determine the level of service, it would be fine to submit the dx, for reporting purposes.