Wiki Z00.01 for annual wellness visit with sick visit

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One of the PCP I code for is always putting through 99213-25 with G0439. I used to assign V70.0 with G0439, and whatever other ICD-9 dx codes with 99213.
Now that we have switched to ICD-10, I am having problems:( I just got back a denial for AWV. I had billed G0439 with Z00.00 and 99213-25 with R21 (rash), I10 (hypertension), and E78.0 (hypercholesterolemia). They denied the G0439.
Should I be have coded Z00.01, R21 with G0439? Is it ok to still bill 99213 for the rash?

I am reading contradicting things online about billing sick visits the same day as AWV in ICD-10. What are the guidelines for this? I've read the Excludes 1 for Z00...still confused??
 
You cannot provide a sick visit and a well visit at the same encounter. The Z00.01 is for a well visit with abnormal findings. These are things not expressed by the patient but abnormalities discovered by the physician during a well visit. If the patient presents with symptomatic complaints/concerns, the exclude 1 note instructs you to code to the symptoms. You cannot bill the well visit at the same encounter. In addition the category description which defines every code in the category state General exam without complaint, suspected, or reported diagnosis.
 
So, in the example I originally gave...the patient would have had to of scheduled his appointment as an annual wellness visit and not had any symptoms or complaints in order to bill G0439 and the dx code Z00.00. Since the patient did end up having a complaint (the rash) then I am no longer able to bill G0439. Instead, bill a sick visit (99213) with dx code for the rash.

Under what circumstances do I use Z00.01 then? If the patient was not aware that he had a rash that had developed, and the doctor was the one that noticed it...then would I code G0439 with Z00.01 & dx code for the rash...but no 99213-25?

Are there any instances where it would still be appropriate to code G0439 at the same time as a 99213-25? I have a PCP who puts this through often! I know I will be seeing a lot more of these visits come across my desk, and I need to know how to properly handle them.
 
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This is a common debate in our office as well. Some hard guidelines would be great! Patients have a hard time understanding that since this is not a true wellness they have to pay a co-pay for the visit.
 
Kristimo said:
This is a common debate in our office as well. Some hard guidelines would be great! Patients have a hard time understanding that since this is not a true wellness they have to pay a co-pay for the visit.
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As a patient and a new coder, i don't understand why so many offices are quick to bill sick visit when very minimal extra work is done. Just because i have high blood pressure doesn't mean i cant go in and just have a regular old preventive exam.

At the carrier I work for we used to only review these when patients send in an appeal. They were nearly always overturned and we would do a take back. Sadly someone decided we should stop taking a copay for the sick visit add on so review of these have fallen to the wayside since there are no complaints. I'm looking forward to some day until i can move to the fraud, waste and abuse area and do an audit on these.
 
I, for one, am still looking for finalization on this topic as it has been appearing off and on in the forum with conflicting answers. The way i see ICD-10 is that business is NOT as usual, when pior preventive and sick visit could be billed on the same DOS. It is my understanding that there seems to be conflict with what the professional associations and specialties advise stating that both CAN be billed. So, for those of you who DO bill for both services, and WHEN you obtain a denial, what authoritative source will you use to support payment for both. In the meantime I'm advising our physicians not to perform both services on the same day, and so far, have received no doubtful disputations on the subject.
 
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I just posted a question similar and would like to know. Patient comes in for annual but doctor addresses HTN and gives Rx along with other meds and labs for chronic issues. Can we not use Z00.01 as this was not a new issue that was presented but rather a chronic issue that is addressed at a wellness visit. Confused.
 
It is not an abnormal finding. To review a preexisting condition and reorder meds is a part of a preventive exam. An abnormal finding is something discovered by the provider during a preventive encounter.
 
Review a pre-existing condition and reorder meds part of preventive exam?

I, like so many others on these forums, am now in the conundrum that ICD10 excludes 1 note for Z00.00 seems to be attempting to overarch CPT guidelines.
I do not agree with your statement regarding pre-existing. How is reviewing a pre-existing condition and reordering meds for same part of a preventive exam? At this point, it is a known condition - so it cannot be "prevented". What source did this come from?

Specifically in CPT it state for codes 99381 - 99387 or 99391-99397 "if an abnormality is encountered or a pre-existing problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem or abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate Office/Outpatient code 99201 - 99215 should also be reported.

Seems to me that if the visit is scheduled as a "well" visit but pre-existing conditions are the focal point of the visit, then it is an established visit for those pre-existing conditions (ONLY) with the "well" visit being rescheduled, if indeed we cannot bill both as CPT advises.
 
To review pre existing conditions and re order meds is preventive. You are continuing treatment of a condition to prevent it from becoming worse and possibly affecting other body systems/organs.
 
What if a patient comes in for an appointment designated as an Annual Wellness Visit comes in as scheduled and states he has a sore throat for the last two days. The provider completes the "comprehensive" components of the AWV and performs an in house strep test, which comes back positive. In theory, the provider could bill the AWV (99381-99397) in conjunction with the established office visit (99211-99215) with the AWV using the Z00.00 code and the 99211-99215 have the J02.0 attached to it, right?
99395
99213-25
Z00.01 (assuming some spotting was discovered during the exam in the ENT section)
J02.0 (positive in house strep test)

Also, under the Z11-Z13 code descriptions, it lists "encounter for diagnostic examination" under the Excludes 1 rule. Which codes fall under that category? Generally, when something is in the 'Excludes 1' rule, it lists the code range and description, but now in this instance. Any thoughts????
 
The excludes 1 note states clearly excludes 1 signs and symptoms-code to he signs and symptoms. . If the patient presents with a sore throat it is not an abnormal finding, you must the symptom only and reschedule the preventive. So no you cannot code the Z00.00 and the J02.0 together in field 21. And since you cannot code them together you cannot link them as you indicate.
 
Debra,

J02.0 is a definitive diagnosis (Streptococcal sore throat), not a sign or symptom. Signs and symptoms are specific to Chapter 18, which are the R-codes as you know. This has been a debate for me and I would consider that an exception if you are dealing with the specifics of the verbiage. Know what I mean?
 
You stated the documentation said the patient had had a sore throat for the last two days, this is a symptomatic presentation. The excludes 1 note states encounter for signs and symptoms. It does not matter that the provider rendered a diagnosis by the conclusion of the encounter. It began as an expressed symptom b the patient and is not an abnormal finding by the provider. The provider did not "discover/ find" that the patient had strep, the provider was prompted by the patient SYMPTOM of sore throat to look for a diagnosis. You cannot call this an abnormal finding.
 
So why did AAPC put out a blog by John Verhovshek on February 8, 2016 saying that cms allows an annual wellness visit but requires a significant, separately identifiable medically necessary E/M services???
 
That has to do with CPT coding and it will be allowed with ICD-10 CM codes only if an abnormal finding is documented. I have not seen this blog but I would be happy to if you can provide a link. I could not locate it.
 
So can you code Z00.00 and a sore throat? No right but why does the article sound like you can? Thank you.
 
at my office when it comes to the medicare AWV I never code just a G0439 because when it comes to medicare it is no longer a head to toe physical its just a wellness visit so if you physician is still doing a review of systems, histories, problem list, etc (like any other office visit) that alone is at least a 99211x25 because the G0439 does not require that stuff to be done. When it comes to commercial insurance its harder to code a physical and a 99211-99215 because the review of systems, hx, vitals, etc is required for the physical part and you cant use those for both so the chart has to be documented to the max to have enough for a phys and an office visit.
 
https://questions.cms.gov/faq.php?id=5005&faqId=3519

What diagnosis code should be used for the Annual Wellness Visit (AWV)?
A diagnosis code must be reported, however, CMS does not require a specific diagnosis code for the Annual Wellness Visit (AWV). Therefore, providers can choose any appropriate diagnosis code.
(FAQ3519)

Just found this on cms.gov website. If this is the case then there no need to use the Z00.00. Thoughts???
 
We bill for the Medicare AWV with either Z00.00 or Z00.01 and we will bill for an e/m if the patient is seen for anything else- sore throat, blood pressure, diabetes anything we are managing or if the patient is having new symptoms, if the patient also has their preventive exam we will also add the 99397 with it. As follows

G0439
99212-25
99397
G0101
Q0091


Never had any trouble with this. Of course your documentation needs to support as well and we let the patient know ahead of time and have them sign an ABN for good measure even though it isn't required for the 99397.
 
The Zoo category states encounter for general exam without complaint, suspected, or reported diagnosis. The Z00.0 subcategory has an excludes 1 note that states encounter for signs and symptoms - code tomthe signs and symptoms.
The CPT book instructions for using the 25 modifier for a regular visit with a preventative specifies that there must be abnormalities discovered or a chronic problem that requires extensive workup (implying the provider finds an abnormality). You cannot use the Z00.01 for a symptomatic patient. The presentation of a problem on the patient's part is not an abnormal finding by the physician.
Just because you get paid for a claim does not necessarily mean it was coded correctly.
 
Just to clarify, is this post stating that ICD-10 guidelines trump CPT guidelines? CPT guidelines state "If an abnormality is encountered...then the appropriate E/M should be reported." Where in CPT is the definition of an "abnormality" described? CPT does not state (at least that I am aware of) that a patient symptom is or is NOT considered an abnormality.

Second, it has always been my understanding that it was compliant to bill a preventive visit and sick visit on the same day if the documentation was supported. I continue to base this finding on 1st Quarter 2016 issue of Coding Clinic for ICD-10-CM and ICD-10-PCS page 34 Q&A - it appears that a new complaint (unrelated to a preexisting condition) can be billed on the same day as a well child visit. Coding Clinic Q&A referenced below:

Question:
A four-month-old female infant is seen for a well exam. The mother reports that the baby has had a runny nose for one week. The baby has been fussy, but without fever, cough, vomiting or diarrhea. On examination, the tympanic membrane was noted to be red and bulging. The patient is diagnosed with acute right suppurative otitis media. How would this encounter be coded?

Answer:
In this case, it would be appropriate to assign code Z00.121, Encounter for routine child health examination with abnormal findings, as the first-listed diagnosis. Assign code H66.001, Acute suppurative otitis media, without spontaneous rupture of ear drum, right ear, as an additional diagnosis. The abnormal diagnostic finding is acute suppurative otitis media. During a routine exam, when a diagnosis or condition is found, it is coded as an additional diagnosis.

In the above Coding Clinic example, the patient's mother reported the acute complaint and the provider addressed it. ICD-10 is considering this acute complaint as an "abnormal finding". Thus, it appears to me that a well child and sick visit could be billed on this day.

I'm really in need of some correct guidance on all of this!!
 
Quaker said:
Just to clarify, is this post stating that ICD-10 guidelines trump CPT guidelines? CPT guidelines state "If an abnormality is encountered...then the appropriate E/M should be reported." Where in CPT is the definition of an "abnormality" described? CPT does not state (at least that I am aware of) that a patient symptom is or is NOT considered an abnormality.

Second, it has always been my understanding that it was compliant to bill a preventive visit and sick visit on the same day if the documentation was supported. I continue to base this finding on 1st Quarter 2016 issue of Coding Clinic for ICD-10-CM and ICD-10-PCS page 34 Q&A - it appears that a new complaint (unrelated to a preexisting condition) can be billed on the same day as a well child visit. Coding Clinic Q&A referenced below:

Question:
A four-month-old female infant is seen for a well exam. The mother reports that the baby has had a runny nose for one week. The baby has been fussy, but without fever, cough, vomiting or diarrhea. On examination, the tympanic membrane was noted to be red and bulging. The patient is diagnosed with acute right suppurative otitis media. How would this encounter be coded?

Answer:
In this case, it would be appropriate to assign code Z00.121, Encounter for routine child health examination with abnormal findings, as the first-listed diagnosis. Assign code H66.001, Acute suppurative otitis media, without spontaneous rupture of ear drum, right ear, as an additional diagnosis. The abnormal diagnostic finding is acute suppurative otitis media. During a routine exam, when a diagnosis or condition is found, it is coded as an additional diagnosis.

In the above Coding Clinic example, the patient's mother reported the acute complaint and the provider addressed it. ICD-10 is considering this acute complaint as an "abnormal finding". Thus, it appears to me that a well child and sick visit could be billed on this day.

I'm really in need of some correct guidance on all of this!!
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A component of a well exam includes checking the infants ears. The issue with the ear was found during the normal course of a preventive exam, which leads to the DX "with abnormal findings." Yes, the mother had concerns of runny nose and so on, but those would not be indicative of the ear condition, and based on the narrative, the provider noted nothing of concern regarding those symptoms, so therefore no additional E/M problem-oriented code would be included. If the provider documented that, upon examination based off the mother's complaints, the infant was found to have, I dunno, a sinus infection, then that could call for the additional E/M code + 25 mod. (But the documentation would have to clearly indicate which portion of the evaluation and exam was done for the well check and which was done to address the problem/complaint otherwise you'd have no idea how to level the E/M code).

One thing to keep in mind also, when you bill out a well visit AND an office charge, the patient's parent(s)/guardian(s) are apt to have a copay come out of that encounter. Whereas, if just the well exam was charged, that would be at no cost. So ultimately you really need to review the documentation and consider how much "additional work" was done to examine and diagnose the problem (in the example, a sinus infection). I can't imagine that would even meet the criteria for 99212 (appx 10 mins). Preventive visits are not time based and if it only takes an additional 5 minutes to determine the sinus infection, is billing the additional E/M necessary (if you could even get to 99212)? And whose to say that the provider wouldn't have discovered that during the well exam? Alternatively, if the mother complained that the baby doesn't move her left arm anymore, then that's a whole different scenario.

The example is coded correctly; the narrative clearly shows the abnormal finding came about via the well exam, not based from the mother's complaints.
 
Awv

G0438/9 does not need a Z code. It's not a preventive visit.its an annual wellness visit to assess pt"s health risk. A problem focused EM cud be submitted if supported by documentation.Check CMS website fr more info. Also it's payer specific.
 
sujaya101 said:
G0438/9 does not need a Z code. It's not a preventive visit.its an annual wellness visit to assess pt"s health risk. A problem focused EM cud be submitted if supported by documentation.Check CMS website fr more info. Also it's payer specific.
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If it's Medicare, you should refer to your local MAC about the assignment of a Z code. The MAC for my area requires one.

In the example regarding the peds well visit, this might help:
https://www.aap.org/en-us/Documents/coding_factsheet_brightfuturespreventivemedicine.pdf
 
As of October 1st, 2016 sick and preventive/wellness visits can no longer be coded together on the same day. Healthcare Business Monthly has an article in the July issue explaining why.
 
Response to article

danskangel313 said:
Link?
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I consider this the author's opinion (just like all articles contributed to AAPC). AAPC puts a disclaimer out in every magazine that this is not their opinion and to refer to authoritative sources. My suggestion is to follow that advice. Continue to follow your local MAC or insurance carrier directives, as My MAC clearly states that the AWV can be billed with a sick visit.
 
mscorella1 said:
I consider this the author's opinion (just like all articles contributed to AAPC). AAPC puts a disclaimer out in every magazine that this is not their opinion and to refer to authoritative sources. My suggestion is to follow that advice. Continue to follow your local MAC or insurance carrier directives, as My MAC clearly states that the AWV can be billed with a sick visit.
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There was mention of an article in Healthcare Business Monthly. I was asking for a link to that article so I could read it also.
 
It is interesting to note that the author of the article in Healthcare Business is Debra Mitchell who has made several comments on this thread.
 
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