# Routine exam



## nc_coder (May 24, 2013)

The way the coding guidelines are now, we can file a separate E/M at the same time as a preventive exam.  With the new I-10 codes, there is a code for encounter for medical exam without abnormal findings Z00.00 and a code for exam with abnormal findings Z00.01.  With this addition, will this mean the separate E/M would not be used?


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## mitchellde (May 24, 2013)

Maybe.  The documentation would have to clearly reflect that the patient had no complaints or issues, then upon the exam the provider finds a problem that was unexpected.
But rather than a preventive with an ov why not bill a high level supported by the document with the 33 modifier.


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## nc_coder (May 24, 2013)

I thought the 33 modifier was only for procedures like a screening colonoscopy that turned diagnostic.


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## mitchellde (May 28, 2013)

There is no restriction to the use of the 33 modifier, it is only that most examples only explain the 33 modifier with the colonoscopy example.  Also I would like to point out that in no way am I promoting fraud which a fellow member has seen fit to point that finger at me..  I am saying that for ICD-10 CM the code states general exam with abnormal finding.. this means the patient cannot present with a complaint and the documentation must be clear about this.  It is not unusual for the provider to find an abnormality during a routine yearly exam.. such as a breast lump.  
The use of the 33 modifier on a high level office visit was first suggested by the AMA in a newsletter in Dec of 2010.  I do not see how in anyway this suggests fraud!


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## mjewett (May 28, 2013)

Do the insurance carriers apply preventative care policies such as "no deductible, and no copay" to a regular E/M code (for example 99214) when billed with mod 33?


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## mitchellde (May 28, 2013)

That is the way it is suppose to work.


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## mjewett (May 28, 2013)

hmmm I hadn't thought of using the mod with E/M I think that could really work, solves the whole is this a prevenative or E/M or both question....


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## mitchellde (May 28, 2013)

I think It will also but do be prepared to appeal it, the payers have been just as confused about the 33 modifier as everyone else.


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## mjewett (May 28, 2013)

Thank you for the info


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## rthames052006 (May 28, 2013)

Interesting topic! I queried my company top ten carriers regarding modifier 33 and they came back with " modifier 33 is not recognized and does not alter payment" but I never though or considered using it on an e/m. 

Has anyone had any success utilizing it?


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## mitchellde (May 28, 2013)

I do not think most use it at all.  I am comming from the point of what I read from the AMA back in 2010 November.  It was then that they stated the main reason for this modifier was specifically this issue of the split billing.  Then when I looked at the Z00.00 codes for general exams it hit me that this would be perfect for that instance when you have a prevent with an abnormality.  I have other rationale but I think I will put it in the coding edge where I can explain it better.


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## rryder1963 (May 29, 2013)

*Additional Information about Modifier 33 can be found*

here...

http://medicaleconomics.modernmedicine.com/medical-economics/news/modernmedicine/modern-medicine-news/when-use-modifier-33-preventive-care

http://www.aapcps.com/news-articles/Mod33not4Medicare.aspx


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## Annette (May 30, 2013)

*CPT rules not changing due to ICD-10*

So in reply to the question of would a routine E/M still be allowed to be coded with a Preventative if there is a new ICD-10 diagnosis for Preventative w/ or w/o seperate problems, I have to disagree.  

There is no authoratative sources that I know of that states the new diagnosis codes would change how we use the Procedural codes.  You would simply use the correct ICD-10 code and code as you normally do.  The 33 modifier is not being recognized by most carriers, as another writer pointed out.  But most of all, unless I am misunderstanding the answer quoted below, why would you change a preventatvie visit to a normal "higher" level?  That is simply abuse of the basic coding rules, not to mention manipulation of the patient's benefits, i.e. one annual physical per year...



"Maybe.  The documentation would have to clearly reflect that the patient had no complaints or issues, then upon the exam the provider finds a problem that was unexpected.
But rather than a preventive with an ov why not bill a high level supported by the document with the 33 modifier.


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## mitchellde (May 30, 2013)

I am not sure what your objection is.  The new ICD-10 CM codes are very clear.. The Z00.0- codes state they cannot be used with symtoms or other stated diagnosis.  within the category it states two choices one with abnormal FINDING and one for without.  This is not manipulating the benefits.  The patient presents for a preventive exam and during the exam the provider discovers something that was not symptomatic for the patient, such as a breast lump, this is then addressed in addition to the rest of the preventive.  So you would use the choice for with abnormal findings, However we must be clear that the documentation clearly supports this choice.. meaning the patient was asymptomatic and the provider discovers the abnormality after examination.  This is not abuse of the patients yearly exam, the patient requested the yearly knowing they had the benefit and this was done.  IF you bill this as the preventive with an OV using the25 modifier the patient then has to pay a copay they did not expect nor request service for.  The AMA is the one that suggested the appropriate way to bill this is by using the level of service supported by the entire note and attach the 33 modifier, this allows the visit to be captured as the preventive and the patient has no copay.
Please read my response carefully!  I am not suggesting anything underhanded or slick or fraud.  Nor is it abuse of any coding rules.  The rule do change with ICD-10 CM.  You need to examine the codes carefully.


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