# billing/coding physical & sick visit together



## pammysue (Oct 1, 2015)

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?


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## mitchellde (Oct 1, 2015)

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


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## Giss3lrivera15 (Oct 1, 2015)

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


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## mitchellde (Oct 1, 2015)

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


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## pammysue (Oct 1, 2015)

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.


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## mitchellde (Oct 1, 2015)

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


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## lorenc00 (Oct 1, 2015)

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.


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## mitchellde (Oct 1, 2015)

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


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## lorenc00 (Oct 1, 2015)

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".


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## mitchellde (Oct 1, 2015)

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.


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## lorenc00 (Oct 2, 2015)

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!


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## mitchellde (Oct 2, 2015)

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.


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## ollielooya (Oct 3, 2015)

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.


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## janny (Oct 3, 2015)

*Chapter Guidance*

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."


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## mitchellde (Oct 3, 2015)

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


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## Cynthia Hughes (Oct 5, 2015)

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.


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## mitchellde (Oct 5, 2015)

Cynthia Hughes said:


> 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.


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## ollielooya (Oct 5, 2015)

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!


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## mitchellde (Oct 5, 2015)

Yes that is the way it currently reads.


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## ollielooya (Oct 5, 2015)

Thanking you for monitoring this particular thread and  helping to make things clear to us, Debra.


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## williafm (Sep 14, 2016)

Is this stated anywhere else? I can only find this being said on AAPC . Our corporate office states it's just an opinion of the interpretation of the rule and that our drs do not need to follow. They can just keep billing sick and well visits together . They want this stated in writing from a governmental body and /or other coding forums  and I can't find anything. 
Me and our other coder agree with AAPC, it seems clear as day sing reading the article in the July magazine 
Thanks.


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## Bpeterson1102 (Sep 14, 2016)

There is a follow up article in the September issue that should help you


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## williafm (Sep 15, 2016)

Thank you.


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## thelton (Sep 15, 2016)

There is also an article in the October 12, 2015 Part B News that addresses this.  It states you can bill a problem visit on the same day as a well visit.


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## jennifermapple@hotmail.com (Sep 16, 2016)

mitchellde said:


> 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




If a patient needs a med check while at their wellness exam, for example for their ADHD meds, is this billable or must they schedule a separate appointment?


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## jennifermapple@hotmail.com (Sep 16, 2016)

*Coding well checks  and med checks*

If a patient needs a med check while at their wellness exam, for example for their ADHD meds, is this billable or must they schedule a separate appointment?


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## hollomanh (Oct 20, 2016)

mitchellde said:


> 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



I know I'm late here, but we have providers on both ends of the spectrum so am researching: some state (and are quite adamant) the time and effort it takes to review and manage chronic conditions is 100% separate from an AWV, and some of them say they wouldn't bill the extra E&M because it's encompassed in the wellness visit.  So I'm researching the issue myself so we can confidently say to them one or the other.  I just have a question about the field 21 and field 24 statement. Since we've been using ICD-10 now for over a year, have you had any issues with this edit being the driving force for a denial?  I've been handed these visits to pre-audit but didn't always have them.  So I know they were sending well visits with the .00 code and sick E&Ms with the diagnostic codes (not saying they did it right, just stating what was previously done).  They would've all appeared on the same claim in box 21.  But they've never actually rejected or denied.  So I was curious to see if that statement was still applicable.

For my own peace of mind when auditing, I take into account the fact that the AWV includes a health risk assessment.  Within the guidelines for the AWV, they link directly to the CDC's article on what an HRA really is.  Pulling pieces of this article, we use the following when explaining to providers why they can't bill their diagnostic E&M for reviewing/managing multiple chronic conditions:

•	Part of the annual wellness visit includes a health risk assessment.  The design of this is for primary prevention to avert disease, secondary prevention to detect illness early and intervene, and tertiary prevention to better manage acute and chronic conditions (the risk factor analysis).  The AWV aims to prevent onset of disease or to slow the progression and exacerbation of existing illness.  It is built with a preventive focus which is in contrast to visits which focus on treating exacerbations or existing diseases.  So it is assumed that chronic conditions or illnesses will be reviewed and managed at the wellness visit for this reason, whether you see them for it only once a year or not.  If there is an issue with one of these conditions and additional, _significant _workup was needed, that can be _taken into consideration_ for billing an E&M outside the wellness. 

The naysayers still balk and fight me tooth and nail.  Some just let it go.  But we would like to have it set in stone to provide the education to our network of physicians so we are all doing it appropriately.


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## john.beitel (Apr 5, 2018)

*wellness and sick*

So why not use Z00.01 for wellness visit with abnormal findings and additional codes for the abnormal findings?
then link the wellness visit to Z00.01 and the 99213-25 to the abnormal findings? ie UTI or Knee effusion?
we bill like this all the time.
thanks
john


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