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billing/coding physical & sick visit together

  1. #11
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    Well, now that ICD-10 is actually here, maybe we need to just wait and see what payers will decide to do. Will they follow the CPT instructional notes for the Preventive Medicine Services section of CPT which allows preventive services and office visit 'sick visits' on the same day? Or will they follow an Excludes1 note in ICD-10-CM? The suspense is killing me!

  2. #12
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    The ICD-10 CM usage is not up to the payers.. If you read the guidelines it states
    These guidelines are based on the coding and sequencing instructions in the Tabular List and Alphabetic Index of ICD-10-CM, but provide additional instruction. Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA).
    The exclude 1 note is one of these sequencing instructions and its adherence is required under HIPAA. you cannot bypass this or override it with out violating this instruction.

    Debra A. Mitchell, MSPH, CPC-H

  3. #13
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    This discussion is coming up a lot in the forums as I expected it would, similar to the "incident to" issues. Maybe in a future issue of Healthcare Business Monthly there might be an article that specifically addresses these concerns. I expect more providers will be asking about this since obviously it will cut into revenue. Also, having the patients come back another time when they are well to have a preventive may not be too popular of an option. Debra, thanks for your input as always, and it's nice to see other posters comment and question the possibilities. I wish I could wrap my own brain about this to be confident in an answer.
    Suzanne E. Byrum CPC
    Noridian
    NGS

  4. #14
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    This note at the top of Chapter 21 makes me think that this DOES NOT prohibit combined sick and well visits:

    "Z codes represent reasons for encounters. A corresponding procedure code must accompany a Z code if a procedure is performed. Categories Z00-Z99 are provided for occasions when circumstances other than a disease, injury or external cause classifiable to categories A00-Y89 are recorded as 'diagnoses' or 'problems'. This can arise in two main ways: (a) When a person who may or may not be sick encounters the health services for some specific purpose, such as to receive limited care or service for a current condition, to donate an organ or tissue, to receive prophylactic vaccination (immunization), or to discuss a problem which is in itself not a disease or injury . (b) When some circumstance or problem is present which influences the person's health status but is not in itself a current illness or injury."
    Jan Blanchard, CPC, CPEDC
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  5. #15
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    I keep saying it, the exclude 1 note will prohibit coding symptoms with a well adult and well woman. The category description for all Z00 and Z01 codes clearly states encounters without complaint. This is as clear as it can get that you cannot code sick and well together.
    The guidelines also state
    The instructions and conventions of the classification take precedence over guidelines.
    Therefore the instruction of without complaint. And the convention of excludes 1 take precedence over the guidelines for chapter 21

    Debra A. Mitchell, MSPH, CPC-H

  6. Default
    With the exception of the Medicare "Annual Wellness Visit" title, there is no such thing as a wellness encounter or well visit, these are terms that have been applied to the preventive medicine service. Some patients will never be "well" and there is the concern of addressing the whole patient rather than providing care based on billing rules. This "Excludes1" note and the reporting of abnormal findings at a preventive visit will almost certainly be addressed by the ICD-10 Coordination and Maintenance Committee and/or editorial board in the near future. There are other Excludes1 notes that may be changed to Excludes2 in the future due to the same kind of issue. Hopefully, official guidance will be forthcoming in the near future.

  7. #17
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    Quote Originally Posted by Cynthia Hughes View Post
    With the exception of the Medicare "Annual Wellness Visit" title, there is no such thing as a wellness encounter or well visit, these are terms that have been applied to the preventive medicine service. Some patients will never be "well" and there is the concern of addressing the whole patient rather than providing care based on billing rules. This "Excludes1" note and the reporting of abnormal findings at a preventive visit will almost certainly be addressed by the ICD-10 Coordination and Maintenance Committee and/or editorial board in the near future. There are other Excludes1 notes that may be changed to Excludes2 in the future due to the same kind of issue. Hopefully, official guidance will be forthcoming in the near future.
    I don't disagree that some of these need to change but what we currently have is what we are required to work with and it not up to interpretation. So it is either a mistake or the committee had reasons for doing it this way. I am not sure that I agree that there is no such thing as well patient. The presence of chronic conditions does not make a payient not well. If the chronic conditions are stable and well controlled, and the patient has no current symptoms then they are well. I know several people with HTN and diabetes and osteoarthritis that often feel much better than I do on any given day.

    Debra A. Mitchell, MSPH, CPC-H

  8. #18
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    Again, I am learning sooo much from this discussion and basically just want to make something clear. What we were allowed to do last year with respect to the ICD9-guidelines and CPT allowing for both preventive and a sick visit to be billed for the same DOS if documentation supported----we can no longer do that with advent of ICD-10. Do I have this right? This is the question the providers are asking. "No doctor, it is no longer appropriate to bill both visits together for ICD-10 based on the category guidelines and the exclude notes." "sck visits and well visits must be separate encounters based on these rulings."

    Do I understand this correctly?
    Thanks so much for all the input even though there are different opinions. What we used to do or the mindset that this is the way we've always done things definitely must change!
    Suzanne E. Byrum CPC
    Noridian
    NGS

  9. #19
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    Yes that is the way it currently reads.

    Debra A. Mitchell, MSPH, CPC-H

  10. #20
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    Thanking you for monitoring this particular thread and helping to make things clear to us, Debra.
    Suzanne E. Byrum CPC
    Noridian
    NGS

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