Wiki Routine exams with and w/o abnormal findings

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hollyphipps27

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OK I have seen some posts regarding this, but no clear answer...

When do you use the routine exam with abnormal findings codes (ex: Z00.01)? What constitutes an abnormal finding??? I know chronic problems do not, but I am confused about other illnesses. Example: patient comes in for routine (preventative) exam and is also complaining of earache. Provider diagnosed otitis media...abnormal finding or not? Z00.00 or Z00.01? Some say yes and some say only if diagnostic exams are ordered to diagnose it.

HELP!!! :confused:
 
no a patient with a complaint for ICD-10 CM you will code only the complaint and defer the annual, look at the exclude 1 note that states excludes 1 - signs and symptoms , code only the signs and symptoms. An abnormal finding would be something discovered by the provider during the exam of an asymptomatic patient, such as a breast lump.
 
OK so let me make sure I'm understanding...

If patient comes in for well child exam but otitis media is worked up and treated, we would code an office visit with the otitis media dx and not do the well child exam at that time? Tell them to come back for that when well???

But if patient comes in for well woman exam and lump is found, we would code the preventative exam procedure code with annual exam with abnormal finding for dx?

Our providers are not going to like this! They often see patient's for preventative exams and work up other diagnoses at the same time...and bill both together. Yikes. :eek:
 
Yes you have it correct. The big difference is whether the patient has a complaint vs the patient that is fine but the provider finds a problem. Per the affordable care act if the patient presents for an encounter for primarily preventive then you cannot charge a separately reportable office visit. So if the patient presents with a complaint then it is not primarily preventive. See the article in the October coding edge that covers this
 
I don't see that the Excludes 1 regarding encounter for examination of sign or symptom- code to sign or symptom applies to Well CHILD exams Z00.12...so a patient is in for a well child exam and a doctor comes across and treats an ear infection which often happens in children that can't necessarily report their illnesses. We do bill a separate office visit in this scenario. This seems to be a very confusing grey area.

Brenna Peterson, CPC
 
But the well child Z00.12- codes are in the Z00 category which states encounter for general exam WITHOUT complaint, suspected or reported diagnosis. The category description is a part of each code within the the category.
 
So, ICD10 Z00.121 states encounter for routine child health examination with abnormal findings further stating to use additional code to identify abnormal findings. We are using this code if the Provider has identified any new problems like OM or any other abnormal finding. Our providers also bill a separate office visit as long as they show their work is in addition to the checkup (documentation). As for any shots given, I've been told by 2 auditors that the correct way to code them when they're given in connection with a checkup is the checkup ICD10 code as primary and Z23 as secondary but if the patient is only coming in for vaccines then only code Z23. I agree, its all in who you ask..the real answer will come when the claims are processed and paid (or not) by the insurance companies!! :)

Happy ICD10

Annette, CPC
 
The "abnormal" findings are mostly related to annual wellness visits within the GYN spectrum. It was set up for patients that have an annual examination and the physician finds a tumor, polyp or yeast infection while performing the examination. That is when the "abnormal" findings will come into play :)
Hope this helps
 
Debra, I always respect and appreciate your opinions and insights, and have learned much from you. Based on the information below, I have to respectfully disagree with you on coding a routine visit and sick visit at the same time. I am really, as I'm sure most others are as well, trying to fully understand the new guidelines and rules. One would think after all this time, that the WHO, and/or CMS would be more specific in the guidelines, eliminating the need to interpret or speculate.

Regarding when to use routine exam with abnormal findings codes, it was my original understanding that any time a patient had an existing condition that the 'with abnormal finding' should be used. Although, to me, it definitely makes more sense to use the abnormal findings code based on that specific routine exam results, not 'pre-existing' chronic conditions. However, this article reinforces my original understanding. I would greatly appreciate other sources stating that the 'with abnormal findings' codes should only be used based on lab/test/exam results for the current routine encounter.

This article from the American Academy of Pediatrics states:
"...any abnormality that is present at the time of the routine examination
may lead to reporting Z00.121 and a secondary code to describe the finding. This may include, but not limited to an acute injury, an acute illness, an incidental or trivial finding that is diagnosed in the patient?s chart, an abnormal screen, an abnormal exam finding (eg, scoliosis), a newly diagnosed chronic condition, or a chronic condition that had to be addressed (excluding medication refill) due to it being uncontrolled or new issues arising."

Regarding routine and sick visit coding at the same time (supported of course):

The article also answers this question:
"Q.
If we report the Z00.121 (health exam with abnormal findings) code, are we required to report a CPT code for a ?sick? encounter? Also, by using this code will it negate the use of modifier 25?
A.
Please be aware that the new ICD-10-CM code does not impact any CPT guideline. Just because an abnormality is discovered during the routine well child exam does not mean that a separate E/M service should or can be reported. If the criteria are met for reporting a significant and separately identifiable E/M service in addition to the preventive medicine service, then yes one should be reported. However, simply reporting the Z00.121 does not automatically equate to a separate E/M service. As for modifier 25, again CPT guidelines will not be effected, therefore, yes if you are reporting 2 distinct E/M services, then modifier 25 is still required on the ?sick? office visit code."

https://www.aap.org/en-us/Documents/coding_faq_coding_encounters_icd_10.pdf

I have been scouring the internet, as I'm sure others are as well, looking for more definite guidance on these important issues. If anyone has other sources, please post. This is a great thread!

Arrana Ashton, CPC, CEMC
 
arrana said:
Debra, I always respect and appreciate your opinions and insights, and have learned much from you. Based on the information below, I have to respectfully disagree with you on coding a routine visit and sick visit at the same time. I am really, as I'm sure most others are as well, trying to fully understand the new guidelines and rules. One would think after all this time, that the WHO, and/or CMS would be more specific in the guidelines, eliminating the need to interpret or speculate.

Regarding when to use routine exam with abnormal findings codes, it was my original understanding that any time a patient had an existing condition that the 'with abnormal finding' should be used. Although, to me, it definitely makes more sense to use the abnormal findings code based on that specific routine exam results, not 'pre-existing' chronic conditions. However, this article reinforces my original understanding. I would greatly appreciate other sources stating that the 'with abnormal findings' codes should only be used based on lab/test/exam results for the current routine encounter.

This article from the American Academy of Pediatrics states:
"...any abnormality that is present at the time of the routine examination
may lead to reporting Z00.121 and a secondary code to describe the finding. This may include, but not limited to an acute injury, an acute illness, an incidental or trivial finding that is diagnosed in the patient?s chart, an abnormal screen, an abnormal exam finding (eg, scoliosis), a newly diagnosed chronic condition, or a chronic condition that had to be addressed (excluding medication refill) due to it being uncontrolled or new issues arising."

Regarding routine and sick visit coding at the same time (supported of course):

The article also answers this question:
"Q.
If we report the Z00.121 (health exam with abnormal findings) code, are we required to report a CPT code for a ?sick? encounter? Also, by using this code will it negate the use of modifier 25?
A.
Please be aware that the new ICD-10-CM code does not impact any CPT guideline. Just because an abnormality is discovered during the routine well child exam does not mean that a separate E/M service should or can be reported. If the criteria are met for reporting a significant and separately identifiable E/M service in addition to the preventive medicine service, then yes one should be reported. However, simply reporting the Z00.121 does not automatically equate to a separate E/M service. As for modifier 25, again CPT guidelines will not be effected, therefore, yes if you are reporting 2 distinct E/M services, then modifier 25 is still required on the ?sick? office visit code."

https://www.aap.org/en-us/Documents/coding_faq_coding_encounters_icd_10.pdf

I have been scouring the internet, as I'm sure others are as well, looking for more definite guidance on these important issues. If anyone has other sources, please post. This is a great thread!

Arrana Ashton, CPC, CEMC
Click to expand...
If an abnormality is detected during the exam yes then this is a routin exam with abnormal finding but if the child presents symptomatic then no and I don't feel the article sited is stating to code presenting complaints with a well ness encounter. But the code category descriptor overrides this when it states without complaint. I have researched this thoroughly and clearly the intent is that a patient that presents with complaints is not to be coded as a routine general exam.
 
Is there somewhere that gives guidance on what is or is not considered abnormal findings. For well child checks if they also have allergies I would not consider allergies abnormal findings. What if they are coming in for general yearly health exam but also discussed the DM and HLP would that be coded as abnormal to me they are chronic conditions being addressed in a yearly exam. So what is the rule for what is considered abnormal.
 
We are also having a rough time finding a concise way of explaining abnormal findings to our physicians. The ICD 10-CM has a note that states "nonspecific abnormal finding disclosed at the time of these examinations are classified to categories R70-R94". Those categories are for abnormal findings based on blood, urine, other body fluids, and diagnostic imaging. The examples discussed earlier also make sense as an abnormal finding ie: lump in breast, heart murmor, etc. Do we code an abnormal finding for the categories R70-R94 only or are they expanded into findings by the physician not reported previously by the patient (ear ache, etc.)?
 
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