WCC + Sick Coding

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I am coding a WCC & a sick visit. For medicaid we simply create a separate claim - level 1 or 2 for the sick visit and for the office visit a level 3 or 4 for the WCC. How do I do this for commercial insurance. Do I use a special modifer?

Thank you
Kimberly
 

mitchellde

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After OCT 1,2015 you cannot code a sick visit with a well visit. The ICD-10 CM codes do not allow the codes to be together. The Z00 code catergory description states:
Z00 Encounter for general exam, without complaint, suspected, or reported diagnosis.
The Z00.121 which states with abnormal findings, does not include a symptomatic patient. An abnormal finding is something discovered by the provider while examining an otherwise asymptomatic patient.
This code category descriptor is part of the ICD-10 CM system created by the WHO. Therefore this applies to all payers, including Medicaid.
You may have been paid, however it is incorrect to code a well and a symptomatic patient at the same encounter.
 

ljjulian

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We bill a well visit and sick visit on same claim with modifier -25 on the e/m. We use the Z00 code for the wellness. Never had any trouble with any insurance with this. Although some carriers won't pay for 2 visits on the same day. It's best to call the insurance to see if they allow it first.

Deborah can you send me a link showing where it says we can't do this as of Oct '15? Thank you!
 

RebeccaC

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I believe that is referring to if a condition is found on exam, NOT if the Patient comes in with a complaint in addition to a scheduled well visit. There is nothing saying that you cannot code a well visit with a Z00.149 AND , let's say a 99213/25 with J20._ due to the child coming in stating that he has had a cough for the past week and it turns out to be bronchitis and treatment is prescribed. As long as the E/M is completely documented in addition to all of the WCC visit requirements that finding of bronchitis is not the finding of a well exam, but the result of a separately identifiable E/M. It is very documentation based though.

Rebecca C. - CPC, CPMA
 

mitchellde

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If the patient presents with a complaint then it cannot be a well visit. Again the category states without complaint. Even with a 25 modifier. It is not about the modifier it is about the new ICD-10 CM code set which changed how some things can be done and this is one of them. To use the with abnormal finding, you need a patient with no symptoms or complaints and then the physician discovers an abnormality.
 

mitchellde

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This is for all insurance. The coding guidelines and coding conventions in the ICD-10 CM code book are created by the WHO and are HIPAA mandated to be followed. This is also stated in the coding guidelines. So yes for all payers; Medicaid, Medicare, HMOs, replacement plans, government payers all but work comp, and all commercial.
 
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