# ICD-10: Billing a physical exam with sick visit



## Boop0098 (Oct 2, 2015)

Can we split a physical exam and sick visit into two accounts so there are two claims, one with the pe note and charge and the other with the sick note and charge to the same payer on the same day?


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## mitchellde (Oct 2, 2015)

sibylle said:


> You can bill both the sick visit and the physical exam on the same claim.
> 
> Things to keep in mind when doing this.
> - Is the provider still able to establish a baseline with the pt's illness?
> ...


You cannot bill a sick visit with a wellness visit!  The exclude 1 note is very clear clear on this and the definition of exclude 1 is very clear.  You are instructed to code to signs and symptoms.  This is not a payer issue this is ICD-10 CM!  Please tell me how it is that you feel you can still bill both when clearly the codes state that you cannot.  
This is not a linkage issue.  Excluded 1 means you may not code both codes it does not mean you do not link both codes.
You cannot split it into two claims as one will reject as a duplicate.  You just cannot perform a sick visit on the same day as a well visit.


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## tfeece (Oct 5, 2015)

Debra,
Can you please provide additional information as to how you have determined that a preventative visit can no longer be billed with a sick visit?  I understand what you are saying about the ICD 10 code and excludes 1, but I don't see anything that says this precludes the billing of the prevent/sick visit at the same encounter.

The 2016 CPT book continues to indicate that if a significant, separately identifiable evaluation and management service was provided on the same day as a preventative medicine service, it should be additionally reported.
I'm concerned that you may doing a disservice to physicians offices by indicating that both services can no longer be billed together now that ICD 10 is in effect.


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## mitchellde (Oct 5, 2015)

CPT and ICD are two entirely diffentent systems.  The exclude 1 note in ICD-10 CM is very clear that signs and symptoms are purely excluded and cannot be coded her, you are instructed to code to the signs and symptoms.  It really does not matter what CPT states at this point on this, if you cannot put the codes together, you will have no dx to link to one of the visit codes. Also the category description states "encounter for general exam without complaint, suspected, or reported diagnosis.    
So the code category description and the excludes 1 note both preclude coding a pre entice with a sick visit.  
Now presenting signs and symptoms are not the same as abnormal findings.  An abnormal finding is a well appearing patient with no concerns where the providers finds an abnormality on examination.
If you read the code book, read the categories, and read the definition of the excludes 1 notation , this should be enough to show you that you cannot bill a presenting Ill patient with a supposed well visit at the same encounter.


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## tfeece (Oct 6, 2015)

Hi Deb,
I have in fact read the conventions, general coding guidelines and chapter specific guidelines... yet I don't come to the same conclusion as you.   I'm hoping a moderator from AAPC can step in to provide some sort of guidance on behalf of AAPC, or that perhaps they can include this issue in their next publication, so that we can have the official word on this and can be comfortable in how we are coding for these situations.


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## mitchellde (Oct 6, 2015)

I am sorry but it is very clear in the book.. The Catergory description states
Encounter for general exam without complaint, suspected, or reported diagnosis
Under Z00.0 and the Z01 category is the excludes 1 note that states
Excludes 1 encounter for signs and symptoms-code to the signs and symptoms.
Excludes 1 notes are pure exclusionary notes indicating that they cannot be coded together
So by the category description and the excludes 1 note, if a patient presents for a preventive encounter but has a symptomatic issue then you have to code to the symptom and reschedule the annual.
I am not sure why this is not very clear.
The coding guidelines state that descriptions and conventions in the code book have precedence over any guideline.  
I guess my question to you is why do you find this not clear?


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## Bpeterson1102 (Oct 7, 2015)

I'm sorry, but I would question how you find this so "clear"...it is not at all clear and EVERYONE is asking that this be addressed by the coding clinic.  I am also concerned that physician offices will suffer due to your advice. I am a certified coder, I have my icd10 proficiency and I own an icd10 instruction manual published by AAPC which doesn't even address these very questions and or scenarios! 

It is completely unreasonable for a pediatrician to defer a well child/baby exam due to an ear infection or uri. 

The Associate Director of the Practice Resource center for the Washington State Medical Association who is CPC, CPMA, and an AHIMA approved trainer of icd10, wrote me this:

"In general the well child visit would be pointed to the Z-Code with abnormal findings, then you would add the Office visit with the diagnosis pointer to the finding to support the need for the additional service.  

I want to be clear that this is one of the grey areas we are facing with ICD-10  Our understanding is that everything is going to process as it always did but there is some confusion around these services. CPT provides the guidelines for billing a preventive visit in conjunction with an additional office visit. This is fundamentally not changing but the diagnosis codes are and that may cause a glitch. We are advising clinics to monitor these services closely. Please let me know if you have any additional questions.  Thank you."


We will be monitoring our claims closely and anxiously awaiting a definitive update from the coding clinic.

Brenna, CPC


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## mitchellde (Oct 7, 2015)

When I have questioned people regarding ICD-10CM and their issues with understanding, I am finding that most have not looked at the codes in a codebook.  They are finding them in an electronic data base or off of a cheat sheet they purchased or made.  And even those that did find the codes in the book did not read everything associated with these codes.  When you look at the codes out of context they just state encounter for general exam with or without abnormal findings.  The decimal in the codes indicates the codes are an extension of the category.  The category description is a part of every code in the category.  The category clearly states encounters without complaint.  This is why it is very clear to me, but others that were not taught to always look at the category are having a difficult time.
The reference you site was addressing a well encounter with abnormal findings. 
You stated:

"In general the well child visit would be pointed to the Z-Code with abnormal findings, then you would add the Office visit with the diagnosis pointer to the finding to support the need for the additional service. [/B]
 They did not address a symptomatic patient that presents for preventive.
A patient that presents for a complaint of ear pain or cold or fever is not well and it is completely appropriate to reschedule the preventive encounter. This is what I have stated repeatedly and your reference seems to agree.
No office or provider will suffer from this advice
I personally would not bill with a separate office visit since the affordable care act indicates that when the reason for the encounter is preventive, you cannot charge a separate office encounter with a copay.  I follow the AMA advice and drop the preventive code bill an office level with the 33 modifier.


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## Bpeterson1102 (Oct 7, 2015)

Like I said, we'll be awaiting the definitive clarification from the coding clinic. I mean, really...of course I've read the book and all the guidelines. I simply just don't agree with you.
And the reference I sited was answering my email about billing a sick visit with a well visit FYI.


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## mitchellde (Oct 8, 2015)

Yes and they answered stating you can bill a preventive with abnormal findings.  That is not the same as a sick and well visit.  That is a well visit for an asymptomatic patient where the provider discovers an abnormality, this is not the same as a a sick and well visit so in reality they did not address your question directly.  I don't expect that coding clinics will be any different than what is clearly stated in the definition of the code in book.


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## Bpeterson1102 (Oct 8, 2015)

My email clearly asked if I would choose abnormal findings for an ear infection.

 I totally understand what the book says and if you're just trying to educate someone to pass a certification exam, I get it. This is not going to fly in real world coding, specifically for me in a pediatricians office. And yes, there are payer specific guidelines that we follow in accordance with our contract with an insurance company. I guess kind of like how you're saying the ACA apparently overrides CPT guidelines. I do believe this will be addressed.


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## mitchellde (Oct 8, 2015)

Bpeterson1102 said:


> My email clearly asked if I would choose abnormal findings for an ear infection.
> 
> I totally understand what the book says and if you're just trying to educate someone to pass a certification exam, I get it. This is not going to fly in real world coding, specifically for me in a pediatricians office. And yes, there are payer specific guidelines that we follow in accordance with our contract with an insurance company. I guess kind of like how you're saying the ACA apparently overrides CPT guidelines. I do believe this will be addressed.



No I am not teaching for exams I am teaching diagnosis coding.  This has nothing to do with CPT.  The coding conventions in the book as well as the coding guidelines are mandated under HIPAA to be adhered to.  Payer guidelines cannot override diagnosis definitions, conventions, or guidelines.
If the ear infection is discovered in a patient that a patient that appears asymptomatic then it is an abnormal finding.  If the patient presents with the complaint of an ear pain , fever, etc then it is a presenting complaint and it cannot be billed with the preventive.  Real World stuff! I never stated ACA guidelines.  I stated what is covered in the coding guidelines and as descriptions on the code book.  
To be clear this is diagnosis coding.  CPT rules and conventions cannot change how the DX can be coded.  These are two entirely different systems created by totally different entities for completely different purposes.  I am addressing diagnosis only.


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## Bpeterson1102 (Oct 8, 2015)

Thanks! I think this is what I've been arguing...I get it. Have a great day.


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## tmoss1 (Oct 8, 2015)

*well visit question and modifier 33 question*

Hi. I just read the previous post. They were very helpful. I have a couple of questions. When you said you would drop the preventative and just code an office E & M and add a 33 modifier. Can you please explain adding the 33 modifier. I am not clear on that. Why would it be added?  Also can you please tell me if this example would be considered with abnormal or without abnormal findings. A teen who is seen for a preventative visit with no complaints and the provider noted hyperpigmented macules on forearms & abdomen and excoriated papules on forearms. The teen said they were flea bites.


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## saoire (Nov 24, 2015)

*Preventative with a sick visit*

Yes you can bill both. The modifier 25 needs to be appended to the Preventative CPT code not the E/M sick CPT ( 99212-99215) as far as ICD 10 linking you cannot link the same codes for each as the appended E/M is a " by the way" scenario and insurance will reject . So if the preventative dealt with 4 DX link those only .. The sick visit will have seperate DX linked. As long as the physician can justify that E/M level with time and DX they will pay. I have a 100% success rate before and after ICD 10 transition . Make sure your physician knows the documentation requirements in case of audit . There should be two seperate notes.


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## mitchellde (Nov 24, 2015)

saoire said:


> Yes you can bill both. The modifier 25 needs to be appended to the Preventative CPT code not the E/M sick CPT ( 99212-99215) as far as ICD 10 linking you cannot link the same codes for each as the appended E/M is a " by the way" scenario and insurance will reject . So if the preventative dealt with 4 DX link those only .. The sick visit will have seperate DX linked. As long as the physician can justify that E/M level with time and DX they will pay. I have a 100% success rate before and after ICD 10 transition . Make sure your physician knows the documentation requirements in case of audit . There should be two seperate notes.



You may have had success .. However it is not compliant.  ICD-10 CM conventions exclude using a symptomatic problem with a general wellness visit.  It truely does not matter that CPT indicates that both can be done.  This is not a diagnosis linking issue.  It is the same as billing fatigue with depressive disorder.  The excludes 1 note says these cannot be used together and again it is not a linking issue.


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## ollielooya (Nov 24, 2015)

I'm gonna stick my head back in here as a thought occurred to me about the possibility of future audits regarding this type of issue.  As I see it, there really are two camps of thought.  Debra, if you were auditing for a payer, you'd see reasons for them to request takebacks, right, which could be a substantial amount!  On the other hand, what about those who might audit based on believing that both visits can be billed and if the provider submitted the documentation that they felt satisfied the criteria, how would that all play out?  I'm gonna bring this up at our next  chapter meeting to see how many of us are divided on this issue....


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## mitchellde (Nov 25, 2015)

Even if I were auditing on behalf of the provider I would call it incorrect due to the ICD-10 CM conventions.  The category description for the Z00 and Z01 category's as well as the excludes 1 note clearly states that you cannot code these codes with complaints.  It really is very clear.  I fail to see how this is an issue at all.  They cannot be coded together, the excludes 1 rule does not say they cannot be linked together.  So put me as a provider auditor to fight a payer, or a payer auditor to request take backs, the answer on this issue will be the same,  you cannot perform a sick visit at the time of a well visit.


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## Jackie1973 (Dec 2, 2015)

*Need Help with denial*

I got a denial for billing a preventive visit with and office visit with and injection.  I put an 25 modifier on the OV and I got everything paid but the Preventive visit.  They denied stating the Preventive can not be billed with the 96372 with out the appropriate modifier.  HELP  do I move the modifier to the Preventive????


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