Wiki well visit scenario ICD-10

[pedassocjc]

An established, 11 year old female presents to the office for her annual wellness exam. Patient also mentions she has noticed some bumps on her abdomen, which the doctor diagnoses as Molluscum Contagiosum. She is due for immunizations: Tdap, Menactra and HPV-9. Doctor orders a CBC(finger stick) and Urinalysis. Patient has a BMI of 50% and the doctor counsels the patient regarding nutrition and exercise. The physician did not spend enough additional time to bill separately for the treatment of the Molluscum.

99393 Z00.121, B08.1, Z23, Z71.3, Z71.89 (is this order correct?)

(would we use the ABN well exam code here?)

90715 Z23
90651 Z23
90734 Z23
90460(X3) Z23
90461(X2) Z23
36415 Z00.121
85025 Z00.121
81002 Z00.121

Thank you for any help!

 

[mitchellde]

If the patient has the complaint/symptom of the rash then it is not an abnormal finding, it is a presenting symptom. The Z00 category states general exam without complaint, suspected or reported diagnosis. If there is a presenting complaint you will need to reschedule the well visit. An abnormal finding is something discovered by the provider.

 

[pedassocjc]

Thank you for your response. Is it correct that the Z23 for immunizations should be included in the diagnoses on the office visit line?