# Preventative Visit with chronic conditions addressed



## traci.susong@gmail.com (Nov 23, 2015)

Hello all,

I hope this isn't a repeat question but would like some guidance. If a patient is being seen for their annual preventative visit and the provider addresses their chronic condition (i.e. HTN) and prescribes their meds (refills for HTN), can we use the Z00.01 diagnosis code? OR does this turn into an established visit. The providers do not code two visits at one encounter (e/m-25 and preventative). Need clarification on when Z00.01 is appropriate to use as a diagnosis. 

Thanks


----------



## CodingKing (Nov 23, 2015)

You can have a chronic condition and get an RX refill during a physical. That's not good enough to bill a separate E&M. Is still billable with the preventive visit code.


----------



## mitchellde (Nov 23, 2015)

traci.susong@gmail.com said:


> Hello all,
> 
> I hope this isn't a repeat question but would like some guidance. If a patient is being seen for their annual preventative visit and the provider addresses their chronic condition (i.e. HTN) and prescribes their meds (refills for HTN), can we use the Z00.01 diagnosis code? OR does this turn into an established visit. The providers do not code two visits at one encounter (e/m-25 and preventative). Need clarification on when Z00.01 is appropriate to use as a diagnosis.
> 
> Thanks



You would use the Z00.00 not the Z00.01.  To review pre existing conditions and reorder meds is not an abnormal finding.  An abnormal finding is something out of the norm that is discovered by the provider in the course of a well visit exam. Such as a breast lump or lab values outside the normal expected.


----------



## Restevez1989 (Nov 24, 2015)

In this situation I would use the dx Z00.00 only because this is a chronic condition and not something that was found during the physical exam. I would also code a 99212 or 99213 an append modifier 25 given that a condition even (chronic) was discussed during the same encounter. That DOES qualify for an E/M visit as well.


----------



## CodingKing (Nov 24, 2015)

Rejr89@aol.com said:


> That DOES qualify for an E/M visit as well.



It does not automatically qualify. It has to be able to be documented as a standalone E&M. if you couldn't put these on 2 separate encounter forms and still meet the criteria for an E&M minus the items performed during the physical you cannot bill it.

The key word in the use of modifier 25 is Significant


----------



## Restevez1989 (Nov 24, 2015)

Ofcourse! It is all based on documentation and what was discussed during the same visit. To my understanding a preventative visit is a 100% WELL VISIT therefore if anything else is discussed even a chronic condition and a reason to possibly adjust the medication there is no reason that does not qualify for a separate E/M visit.


----------



## mitchellde (Nov 24, 2015)

Rejr89@aol.com said:


> In this situation I would use the dx Z00.00 only because this is a chronic condition and not something that was found during the physical exam. I would also code a 99212 or 99213 an append modifier 25 given that a condition even (chronic) was discussed during the same encounter. That DOES qualify for an E/M visit as well.



I disagree.  The patient presents asymptomatic fir the annual preventive.  If the chronic conditions are stable and the provider only inquires as to the status and refills meds, then this is all part of the preventive.  You cannot assess an office visit the patient is not expecting nor requested.


----------



## CodingKing (Nov 24, 2015)

https://www.aapc.com/blog/22580-successfully-bill-a-preventive-service-with-a-sick-visit/



> ?If an abnormality is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem or abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate Office/Outpatient code 99201-99215 should also be reported.?




http://www.physicianspractice.com/c...d-problem-oriented-visit#sthash.UzNX17C5.dpuf



> In the history of the present illness, describe the patient's symptoms or her chronic conditions. Don't conserve words. "HTN-stable; DM-okay; Lipids-will check," will hardly justify the addition of a problem-oriented visit.
> 
> Also, if the entire HPI is copied from a previous visit, don't report an additional visit. In the HPI, document pertinent positive and negative systems related to the presenting problem. In the assessment and plan, list the conditions treated and changes to the treatment. You should be more likely to report a problem-oriented visit when there is a new acute condition, a worsening chronic condition, a diagnostic test was ordered, or a treatment was changed. Refilling prescriptions for existing problems is not sufficient work to report a problem-oriented visit, in addition to the preventive service.


----------



## mitchellde (Nov 24, 2015)

Rejr89@aol.com said:


> Ofcourse! It is all based on documentation and what was discussed during the same visit. To my understanding a preventative visit is a 100% WELL VISIT therefore if anything else is discussed even a chronic condition and a reason to possibly adjust the medication there is no reason that does not qualify for a separate E/M visit.



And a patient that is asymptomatic is 100% well.  Having chronic conditions does not make you less well.  The provider discussing whether or not to change a medication does not make the patient less well.  
The patient gets to decide how much health care they want.  They have requested a well visit and that is what they get.  If the patient expresses no problem then there is no justification for an additional encounter and ICD-10 CM does not let you have a sick and well visit together anyway.  The provider cannot decide to add another encounter when there is no abnormality discovered and they are only discussing asymptomatic issues.  
So I disagree it does not justify a separate E&M.  I have argued this point with my own physician, and after pointing out that I presented with no problems and no complaints, there was no justification for an additional encounter, he had agree with me.


----------



## Restevez1989 (Nov 24, 2015)

"A problem-oriented visit is one that addresses an acute or chronic condition and documents history, exam, and medical decision making related to the condition - See more at: http://www.physicianspractice.com/coding/coding-both-preventive-service-and-problem-oriented-visit#sthash.UzNX17C5.rYVona1A.dpuf"

Also if a patient needs his or her meds adjusted then there is no reason to say this patient is asymptomatic. I understand your viewing on this but I still disagree and I feel this is something that is different and should be dealt with on a case by case basis. 

If both services are done, follow the CPT rules and report both the preventive service and the problem-oriented visit. - See more at: http://www.physicianspractice.com/c...-oriented-visit#sthash.UzNX17C5.rYVona1A.dpuf


----------



## mitchellde (Nov 24, 2015)

Yes but following the ICD-10 CM rules you cannot bill a preventive encounter with a symptomatic complaint.  Discussing chronic conditions is not an abnormal finding, so you have no diagnosis to attach to the office visit.  The category states, general exam without complaint, suspected, or reported diagnosis.  The chronic conditions would be the reported diagnosis, so they cannot be coded here.  
I just feel we all need to step back and take a breath.  Just because it was done this way prior to Oct 1 and just because CPT states you can do something, does not automatically make it so.  I feel it is wrong to assess an additional visit when the patient presents for wellness and no other issues are discovered.  I think the ICD-10 CM instructions are really clear on this.
Also a preventive visit is not a "problem oriented" encounter to begin with.


----------



## Restevez1989 (Nov 25, 2015)

mitchellde said:


> Yes but following the ICD-10 CM rules you cannot bill a preventive encounter with a symptomatic complaint.  Discussing chronic conditions is not an abnormal finding, so you have no diagnosis to attach to the office visit.  The category states, general exam without complaint, suspected, or reported diagnosis.  The chronic conditions would be the reported diagnosis, so they cannot be coded here.
> I just feel we all need to step back and take a breath.  Just because it was done this way prior to Oct 1 and just because CPT states you can do something, does not automatically make it so.  I feel it is wrong to assess an additional visit when the patient presents for wellness and no other issues are discovered.  I think the ICD-10 CM instructions are really clear on this.
> Also a preventive visit is not a "problem oriented" encounter to begin with.



Actually discussing a chronic condition will have a separate diagnosis from the preventative visit. Lets say the patient has diabetes for example and they come in for there "physical" but then also discuss issues they are having with there diabetes. The Dr then proceeds to take time and discuss the issues with the patient and determine to adjust the medications accordingly, that my friend is not a Physical whether you feel its wrong to add an additional visit. We as coders are responsible to make sure the doctors and facility we work for are getting reimbursed appropriately and to the fullest. To say that CPT can state its ok to do something and ICD 10 says another makes me question a lot. Can you please direct me to where ICD 10 says you cannot bill a preventative visit along with a problem visit?


----------



## mitchellde (Nov 25, 2015)

The category Z00 states encounter for general exam without complain, suspected, or reported diagnosis.  If the patient is having problems with the diabetes then it is not a preventive encounter.  If the patient has just general questions then that is part of the preventive encounter.  The physician must discover an abnormality to be able to bill an additional encounter.


----------



## Pam Brooks (Dec 3, 2015)

I agree with using the Z00.00 for a preventive visit when patient is also being followed for chronic conditions. My understanding with the Z00.01 as it's described is that it is used to additionally report abnormal findings.  An example of this might be a new problem of elevated blood pressure that was discovered as the vitals were taken during the well visit.

As for billing a well visit with an E&M; this has always been a documentation challenge, and I don't see that ICD-10 changes anything in terms of reporting a separate E&M. 

To report an additional E&M visit with a well visit, you must append the -25 modifier.  The use of this modifier is pretty clearly discussed in CCI.  The additional work must be separately identifiable from the well visit (where chronic conditions may also be managed) and significant.  They key word here is "significant" (and actually is mentioned in Betsey Nicoletti's article that Restevez1989 references).  Simply discussing a chronic condition at the time of a well visit does not constitute a significant event, particularly if the condition is stable, and certainly not if the only documentation factor is an additional diagnosis.  In fact, managing chronic conditions where there is no action other than script renewal and possibly surveillance labs is not considered anything other than the routine care you'd provide to the patient.  I do understand the need for providers to be reimbursed to "the fullest" as is also mentioned in Restevez1986's post.  But we wouldn't want to do this at the expense of unbundling these charges when the provider's attention to the problem(s) are not significant to warrant a separate visit.  

What I consider significant (and what I train my physicians) would be a severe exacerbation, a significant change in a treatment plan, or the documentation of a new and acute problem.  In the example above, when the patient presents with elevated BP at the time of the well visit, if the provider doesn't spend a great deal of additional time discussing the finding, doesn't take any additional history, or doesn't implement any plan, I would simply code the Z00.01 and bill just the well visit.  

When you also consider the patient's expectation that a well visit is now delivered to them at no charge (due to ACA),  adding on another charge based on a brief discussion of any condition, whether or not it warrants a different diagnosis,  is going to cause all sorts of patient satisfaction issues.  They're expecting to NOT pay a co-insurance or deductible, and your billing staff can spend a lot of time explaining to patients why they came in once and had two visits.  You're spending more money in resources than you gained through the reimbursement of the additional charge.


----------



## traci.susong@gmail.com (Dec 8, 2015)

In this instance. The patient came in for a preventative and the majority of the documentation centered around his chronic conditions which in turn resulted in refill of meds and labs.


----------



## traci.susong@gmail.com (Dec 8, 2015)

Pam that is what happened. Patient came in for preventative and received a bill for a copay. Notes were coded as a E/M with chronic conditions as diagnosis.


----------

