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New patient wellness and OV

A

annielou

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56
Location
Bentonville, Arkansas
Can a new patient office visit be charged with a new patient wellness? The patient was new to the clinic and the provider, and was scheduled for a wellness visit. The patient also has chronic comorbid medical conditions which were discussed and prescriptions provided. My billing office is telling me one of the charges has to be for established patient, which I think is wrong.
 
I believe so. When I was in primary care we didn't have any issue with the coding. For example:

99202-25
99386

The E/M does need to be separately identifiable from the wellness exam, however. If anyone feels otherwise, please chime in :)

Lena
 
I don't think both should be billed as new. It's been a well since I've worked family practice, but I seem to remember one of the visits being denied when they were both billed as new.
 
I've been advised to charge the new patient for the CPE and the established pt for the sick EM, however, we do both as the providers code their own EM services and both variations slip by at random. To date, we've no denials or issues with either or, but we definitely need to look into this further to get it right.
 
amexnikki23 said:
I've been advised to charge the new patient for the CPE and the established pt for the sick EM, however, we do both as the providers code their own EM services and both variations slip by at random. To date, we've no denials or issues with either or, but we definitely need to look into this further to get it right.
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FYI. If you look at the ICD-10 CM codes you will see the codes for the general wellness exclude1 signs and symptoms. Which means after October 1 you cannot code a wellness visit and a sick visit on the same day for a patient with an expressed complaint or concern.
 
We just had an auditor explain this situation to us yesterday.

You cannot code a new wellness and a new ov on the same encounter. The wellness would be new and the ov would be est.
 
mitchellde said:
FYI. If you look at the ICD-10 CM codes you will see the codes for the general wellness exclude1 signs and symptoms. Which means after October 1 you cannot code a wellness visit and a sick visit on the same day for a patient with an expressed complaint or concern.
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Debra, yesterday there was a thread similar to this and I recall of the members disagreeing about this fact regarding the ICD-10 guidelines, I find it all a little confusing still, and I also do not yet have an ICD-10. Was yesterday's debate resolved? Does this still ring true that a wellness visit and sick visit (if the pt presents with complaints, signs/symptoms, request f-u of chronic conditions to be addressed) cannot be charged on the same DOS?

PS. Also, what I'm gathering from the Excludes1 explanation is that for the wellness visit, I cannot combine a routine exam code with a sick dx code, but that if I add an sick EM visit to the claim, then I can apply the sick dx codes to that. Therefore the wellness exam will not include the sick visit, thus abiding by the Excludes1 rule. Thanks!
 
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The excludes 1 note means you cannot use the Z00.0- or the Z01.- codes with codes for signs and symptoms. The note says to code to the signs and symptoms. It does not mean that you just attach them to different visit codes, it means you cannot submit a claim with both. If the patient has no complaints but the provider discovers an abnormality during the preventive encounter, then you would use the choice that states with abnormal finding. I do know that many disagree and I cannot figure out why. The excludes note is really very clear. Perhaps they are not seeing the excludes note?
 
I have a case where the patient is new to both the office and providers, and presented for an annual wellness visit (Pt was encouraged by insurance company). This Pt is HIV positive, and therefore the provider needs to order all related labs. To code this encounter, do we use the E/M as a new Pt and the wellness as a established Pt? and what about codes Z00 after October 1st?

Please help!!!:
 
I'm not seeing the exclude note, maybe looking in the wrong place? Z00.01 for "Encounter for general adult medical examination with abnormal findings' states to 'Use additional code to identify abnormal findings'. Wouldn't that work?
 
a.renee86 said:
We just had an auditor explain this situation to us yesterday.

You cannot code a new wellness and a new ov on the same encounter. The wellness would be new and the ov would be est.
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Can you cite the source of this information as presented by the auditor? I still cannot find anything proving that this is viable information. My providers will not take AAPC forum members' opinions on this topic :)
 
mitchellde said:
The excludes 1 note means you cannot use the Z00.0- or the Z01.- codes with codes for signs and symptoms. The note says to code to the signs and symptoms. It does not mean that you just attach them to different visit codes, it means you cannot submit a claim with both. If the patient has no complaints but the provider discovers an abnormality during the preventive encounter, then you would use the choice that states with abnormal finding. I do know that many disagree and I cannot figure out why. The excludes note is really very clear. Perhaps they are not seeing the excludes note?
Click to expand...

I understand the rationale behind not assigning the excludes1 dx codes with the Z00.0-Z01. category, but ICD-10 is not designed for claims and reimbursement it is designed for accuracy in assessing reasons for visits, diseases and conditions, so if that is the case, the rules governing billing for separate EMs using sick dx codes would come from the insurance side of things, as well as CPT usage. I still believe that as long as I do not attach the excludes1 dx codes to the wellness, but attach them to the sick EM visit, that I'd be correct, so long as the sick EM is justified (ie. not found on exam, but actual HPI elements). I could be wrong, but right now, that's how I'm thinking, since we're not into ICD-10 yet. At this point, I'm just trying to know when it's ok for a provider to charge separately for an EM. Thx :)
 
amexnikki23 said:
I understand the rationale behind not assigning the excludes1 dx codes with the Z00.0-Z01. category, but ICD-10 is not designed for claims and reimbursement it is designed for accuracy in assessing reasons for visits, diseases and conditions, so if that is the case, the rules governing billing for separate EMs using sick dx codes would come from the insurance side of things, as well as CPT usage. I still believe that as long as I do not attach the excludes1 dx codes to the wellness, but attach them to the sick EM visit, that I'd be correct, so long as the sick EM is justified (ie. not found on exam, but actual HPI elements). I could be wrong, but right now, that's how I'm thinking, since we're not into ICD-10 yet. At this point, I'm just trying to know when it's ok for a provider to charge separately for an EM. Thx :)
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It does not state do not link them together it states to code only to the signs and symptoms. No you will not be able to bill a sick and a well visit together after Oct. 1. Even though we are not into ICD-10 CM yet, it is literally a matter of days.
 
New patient CPe with An office visit, is it to be new or established code?

HI I do wish to also find out what sources can help me have proof that I am to bill an new or established office visit with the new CPE.

thank you.
 
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