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billing/coding physical & sick visit together

  1. Default billing/coding physical & sick visit together
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    attended a seminar on ICD-10 and was told that we will no longer be able to bill for a annual physical and sick visit with the modifier 25 together due to the excludes 1 on the Z code. Is this correct?

  2. #2
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    Yes if you look at the exclude 1 not it states exclude 1 encounter for signs and symptoms - code to the signs and symptoms. Also the definition of the excludes 1 notation is that you cannot code these codes together you may code only one. The Z00 category description states encounter fir general exam without complaint, suspected, or reported duagnosis

    Debra A. Mitchell, MSPH, CPC-H

  3. Default
    so can we still charge for a well baby visit and a sick visit? or this depends of the insurance.? am so confuse

  4. #4
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    No you cannot. Please look at the codes. The Z00 category states WITHOUT complaint, suspected, or reported diagnosis.

    Debra A. Mitchell, MSPH, CPC-H

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    So even though we put the Z code with the PE CPT and the sick DX with the OV CPT with the 25 modifier showing that they are two separate services provided? This is a big change as we have always done it that way with ICD-9. We then will have to have the patient come back to have the other service done.

  6. #6
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    Again the exclude 1 note prevents you from billing symptoms with the well visit. Presenting symptoms cannot be coded as abnormal findings

    Debra A. Mitchell, MSPH, CPC-H

  7. #7
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    These Z00 codes are causing a great deal of confusion and I hope there will be further guidance. I'm not sure I agree that a preventive service and an office visit service cannot be billed on the same day or that the patient would need to come back on another date. This certainly would be onerous to the patient.

    If the physician appropriately documents the elements of the preventive service and then seperately documents an office visit for the work-up of an "Oh, by the way, doc, while I'm here, I've had this knee pain for 2 weeks" type of sign or symptom, this, to me, should not fall under an Excludes1 situation.

    Excludes1 notes apply to diagnosis codes, not CPT codes. You would not be able to bill a preventive service CPT with Z00.00 plus an additional code for the knee pain; but you should be able to bill:
    • 99396 linked only to Z00.00
    • 99213-25 linked only to the knee pain diagnosis

    That's my opinion anyway but am willing to live and learn if more offical guidance comes out.

    My other point of confusion is for patient's coming in for their annual physical, without compliants, but who do have a known stable chronic condition (such as hypertension). This condition is well controlled on meds. During the course of the preventive service the hypertension is addressed but since it is stable no changes to medications are made. This would be considered inclusive to the preventive service; but I'm wondering if the known, stable condition is still considered an 'abnormal finding' for as long as the patient has the hypertension and therefore the preventive service could go always go out as 99396 with Z00.01 and I10.

  8. #8
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    The exclude 1 note will be the driving factor. You canot code a symptom with a wellness, the directive is to code to the symptoms. An abnormal finding is not the same as a presenting symptom.
    Stable chronic conditions are neither symptoms nor abnormal findings, but you cannot charge a separate visit level to reorder meds for these issues
    You cannot use the two dx codes together on the claim due to the excludes 1. It is a field 21 edit not a field 24 edit. It does not matter how you link them, the edit applies to the listing of the codes on the claim in field 21
    Last edited by mitchellde; 10-01-2015 at 12:43 PM.

    Debra A. Mitchell, MSPH, CPC-H

  9. #9
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    Ok, so if payers are going to reject claims based on diagnosis entries in field 21, then wouldn't the solution be to bill out on two separate claims so that field 21 is not an issue - rather then tell patients they have to come back on another date?

    If we see rejections on this (and I'm not entirely convinced we will) then we will instruct our billing system to edit when a combination visit of a preventive with Z00.00 and an office visit-25 with complaints comes through. We will then have it split out into two claims, rather than our inconvenience patients.

    I'm aware of the difference between an abnormal finding and complaints/presenting symptoms but appreciate your guidance about the stable chronics. I had already instructed coders and physicians that a preventive service without complaints, without abnormal findings, but with stable chronics should be coded with Z00.00 only. But it seems a shame to have to exclude stable chronics because of the ever increasing risk adjustment/HCC models for payment. These models want all the patient's conditions reported at least once a year to show severity of illness for per capita payments the following year. This reporting usually occurs at an "annual".

  10. #10
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    Two claims submitted on the same day by the same provider, one will be rejected as a duplicate claim. I don't understand why all the effort to work around this issue. The patient schedules the encounter for a WELLNESS visit, so they should be well. If they have a symptom then it is not wellness and must be attended to as a sick encounter and reschedule the wellness for a time when they are well. it is just setting the office up for rejections, and if they happen to slide thru there is the ever present issue of future take backs.
    Last edited by mitchellde; 10-01-2015 at 05:22 PM.

    Debra A. Mitchell, MSPH, CPC-H

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