QUESTIONING THIS AFTER AUDIT
Patient came in for Annual Exam.
HX of Present Illness
rovider goes over patient having multiple problems in personal hx and family hx , states pt has hip pain from something yr prior but is worse now when standing and her wrist pain of old issue has worsen and refilled meds for hyperlipidemia. Provider does Physical Exam, review of symptoms, Past & Social hx also and with no wellness form completed. We are a RHC and this is a commercial insurance patient.
Provider coded the wrist pain primary dx, then hip pain, 3rd hyperlipidemia and last code Z00.00 with 99214. Provider did ordered x-ray for wrist pain and did routine labs in assessment attached to the Hyperlipidemia Dx and Z00.00 Dx.
So should this be a 99396 not 99214 with primary dx as Z00.01 then dx for wrist, hip and hyper below it or would you leave problem dx's and 99214 and take off Z00.00 as last dx?
***But in recent audit of another patient auditor didn’t like that a provider addressed issues and did labs attached only to dx Z00.00 with CPT 99396 and E & M 99213. Auditor said to take off the 99396 as not enough counseling documented for Z00.00 and labs just thrown in, bill for the office visit but she left all the dx problems and put Z00.00 as last Dx like this pt.
ICD10 Appendix E says: Z00.00 only as Principal/First Listed Dx
ICD-10 DX Description says: Z00.00 Encounter for general adult medical exam without abnormal findings) Z00.01 is with abnormal findings.
Chapter 21 Guidelines for Z00.00 says: Following Z codes/categories may only be reported as the principal/first-listed diagnosis, except when there are multiple encounters on the same day and the medical records for the encounters are combined.
Patient came in for Annual Exam.
HX of Present Illness
rovider goes over patient having multiple problems in personal hx and family hx , states pt has hip pain from something yr prior but is worse now when standing and her wrist pain of old issue has worsen and refilled meds for hyperlipidemia. Provider does Physical Exam, review of symptoms, Past & Social hx also and with no wellness form completed. We are a RHC and this is a commercial insurance patient. Provider coded the wrist pain primary dx, then hip pain, 3rd hyperlipidemia and last code Z00.00 with 99214. Provider did ordered x-ray for wrist pain and did routine labs in assessment attached to the Hyperlipidemia Dx and Z00.00 Dx.
So should this be a 99396 not 99214 with primary dx as Z00.01 then dx for wrist, hip and hyper below it or would you leave problem dx's and 99214 and take off Z00.00 as last dx?
***But in recent audit of another patient auditor didn’t like that a provider addressed issues and did labs attached only to dx Z00.00 with CPT 99396 and E & M 99213. Auditor said to take off the 99396 as not enough counseling documented for Z00.00 and labs just thrown in, bill for the office visit but she left all the dx problems and put Z00.00 as last Dx like this pt.
ICD10 Appendix E says: Z00.00 only as Principal/First Listed Dx
ICD-10 DX Description says: Z00.00 Encounter for general adult medical exam without abnormal findings) Z00.01 is with abnormal findings.
Chapter 21 Guidelines for Z00.00 says: Following Z codes/categories may only be reported as the principal/first-listed diagnosis, except when there are multiple encounters on the same day and the medical records for the encounters are combined.
