# Annual Preventive & E/M on the same day



## Edithcha (Dec 9, 2015)

Hello 

I need help in coding for the following case:

Established patient presents for the annual preventive visit, but also complains about chest pains. MD did the E/M for the chest pain and an EKG with interpretation & report in house. In addition, MD performed full exam on patient, ordered all labs, and referrals accordingly.

My question is: Can I bill for the preventive visit (99394-99397), the E/M for the chest pain (99211-99215) and the EKG (93000)??? 
Help please!!!!!


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## mitchellde (Dec 9, 2015)

You cannot code the well diagnosis code with the complaint dx code.
Z00 encounter for general exam without complaint, suspected or reported diagnosis
The category descriptor does not allow these to be together.
Z00.0
Excludes 1 encounter for signs and symptoms-code to the signs and symptoms
The exclude 1 note means these are purely excluded and cannot be coded together, and you are instructed to code only the signs and symptoms.
Therefore since the patient complained of chest pain, it is not an abnormal finding and can only be submitted as an encounter for the symptom of the chest pain.


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## Edithcha (Dec 9, 2015)

Thank you Debra for your input. 
So, does this mean that I can only bill the E/M with the EKG, and not the preventive portion of the visit???


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## Bpeterson1102 (Dec 9, 2015)

The answer provided below is from the Washington State Medical Association Practice Resource Center:

It is important to remember that there are different rules for different code sets. Per CPT, you can bill an office visit and a Preventive on the same day if you meet the criteria to use Modifier 25.  This also applies when billing an office visit in conjunction with a minor procedure. If the office visit is significantly identifiable and goes above and beyond what is required for the other procedure or visit you can bill for both services.  Again the rules for this tend to be payer specific and depend on if other services are billing. 

  The AAPC issue, that Debra is referring to,  is more complicated.  Technically under ICD-10 there is a Type 1 Excludes under Z00.0 (Base Preventive DX) that states you should not code a sign or symptom with a preventive service.  The issue is how this rule is being interpreted. Some, like the contributor to the AAPC forum, think this means you cannot bill an additional office visit with the preventive. There are other coder and organizations that disagree with this interpretation because the implementation of ICD-10 was not suppose to change the way we fundamentally billed services before the implementation. This interpretation would have huge financial problems for practice across the country and the general consensus is that this interpretation only applies in certain clinical scenarios.  It depends on the situation as well as the documentation. See below. 

  ?        If the reason of the visit is for evaluation of a sign or symptom then you would simply assign the sign or symptom code and not the general exam code.   So it is important to have clear documentation as the what the patient was coming in for at the time of service a well child or to have a problem accessed. 

?        If a patient comes in for a preventive exam and half way through the visit says "Oh, by the way....", then the physician can address that problem specifically outside of the routine exam (provided they have time and is something they can do) and code for the preventive exam and an E&M as long as the documentation for the E&M is separate. They must also include modifier 25 with the E&M code. 

?        If the patient comes in for their preventive exam and then complains of an acute condition that needs to be addressed, then that would supersede the preventative exam which would be rescheduled. And, of course, if the patient has a sign/symptom that needs to be addressed by a specialist, then the physician could give a referral and would code the preventative exam. 

  From a coding perspective, there is nothing that states that a provider cannot code for a Preventative exam and an E&M on the same day, same claim. So my interpretation that seems to be playing out with payers is that the excludes note wouldn't apply if the diagnosis for the preventative exam CPT is separate from the diagnosis for the E&M CPT. Just as if a physician bills for an office visit and a minor procedure on the same day, each CPT code can carry a unique diagnosis. The diagnosis pointer on the claim would link the Z00.00 to the CPT for the preventative exam and then another pointer links the E&M CPT to the sign/symptom or condition. The use of Modifier 25 would trigger the E&M as a separately identifiable E&M so the Excludes note isn't applicable.


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## mitchellde (Dec 9, 2015)

Bpeterson1102 said:


> The answer provided below is from the Washington State Medical Association Practice Resource Center:
> 
> It is important to remember that there are different rules for different code sets. Per CPT, you can bill an office visit and a Preventive on the same day if you meet the criteria to use Modifier 25.  This also applies when billing an office visit in conjunction with a minor procedure. If the office visit is significantly identifiable and goes above and beyond what is required for the other procedure or visit you can bill for both services.  Again the rules for this tend to be payer specific and depend on if other services are billing.
> 
> ...


I am sorry but I do disagree.  The use of the 25 modifier does not override the excluded 1 note.  The ICD -10 CM code set is very clear on the definition of the excludes 1 note and it means you cannot code the codes together, you may only code one.  The WHO did admit recently that there are a few isolated errors in the instructions with some codes and they will be fixing it.  They did put out an INTERIM advice to clarify this for the short run.  Things like an ankle fx cannot be coded with a traumatic amputation needs a qualifying statement for if it is the same limb.  You cannot code a symptom with the Z00.00 even when using the 25 modifier.


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## Bpeterson1102 (Dec 10, 2015)

I personally interpret that excludes 1 note to let people know, maybe less experienced coders, that if you're coding an "encounter" for a problem focused visit you don't need this code to say  " general examination of an adult..." you just code the signs/symptoms. ie: Do not put this "encounter for a general examination" code on a 99201-99215. That is "not coded here!". The excludes 1 note is meant to exclude putting that DX on the "ENCOUNTER for examination of signs and symptoms" 
 The very directions tell you to use an additional code for abnormal findings. Without auditing every claim there is no way to know whether the additional code is an abnormal finding or a reported sign or symptom but regardless the codes are the same and they are telling you to code them together.


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## mitchellde (Dec 10, 2015)

Only the the one that states with abnormal findings tells you to add a code for the abnormal finding.  An abnormal finding is not the same as a presenting symptom.  If there are no abnormal findings then you would use the code for without abnormal findings.  The definition of the excludes 1 notation is in the coding guidelines and it is not the same as what you have stated.  Excludes 1 means that the codes cannot be coded together.  There is no exception in this definition and it has nothing to do with your visit level billing.


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## NishaJ (Jan 28, 2017)

As per the ICD 10 CM -2017, we can bill both annual preventive and sick visit on same day as per the newly added statement in  Excludes 1 

 a. Excludes1
A type 1 Excludes note is a pure excludes note. It means “NOT CODED HERE!” An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.
An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each other..

Based on this , we can bill both service with the supporting documents.


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