# Coding chronic conditions with preventive well-checks



## pedscoder21 (Sep 29, 2015)

What are the 'rules' on coding chronic conditions with preventive well-checks (99381-99395)?

For instance - 

1) If an autistic patient presents for his annual well-check and the provider only references the autism in the neurological exam, would you or would you not code the autism with the V20.2/V70.0? As a side note, these conditions are always listed in the patient's "problem list" in our EHR.

2) If a patient presents for a well-check and has diabetes which is noted to be stable in the assessment, would you code it?

I would greatly appreciate any guidance on this topic and/or references!

Thank you


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## mitchellde (Sep 29, 2015)

The ICD-10 CM code categories for the general preventive state "without complaint, suspected , or reported diagnosis".  So no I would not code any of the chronic conditions as I consider those to be the other rooted diagnosis.  And if the patient presents with a complaint the you cannot perform the wellness on the same day.


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## pedscoder21 (Sep 29, 2015)

mitchellde said:


> The ICD-10 CM code categories for the general preventive state "without complaint, suspected , or reported diagnosis".  So no I would not code any of the chronic conditions as I consider those to be the other rooted diagnosis.  And if the patient presents with a complaint the you cannot perform the wellness on the same day.



Hi Debra,

Thanks for your quick response!

When you say "if the patient presents with a complaint then you cannot perform the wellness on the same day", could you clarify?

What if the patient presents for a wellness and the physician completes the wellness exam as well as addresses a patient complaint of frequent headaches? Then we can still bill the wellness with an e/m, correct? (provided that all e/m guidelines are met).


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## mitchellde (Sep 29, 2015)

Read your ICD-10 CM code book the Z00.0 and the Z01 categories have an exclude 1 note that states exclude 1 encounter for signs and symptoms- code to the signs and symptoms.  So as of Thursday you cannot code a well visit and a symptomatic complaint on the same encounter.


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## pedscoder21 (Sep 29, 2015)

mitchellde said:


> Read your ICD-10 CM code book the Z00.0 and the Z01 categories have an exclude 1 note that states exclude 1 encounter for signs and symptoms- code to the signs and symptoms.  So as of Thursday you cannot code a well visit and a symptomatic complaint on the same encounter.



Hi Debra,

Thank you, I did read that. I guess I'm still confused  what would you do for the example I gave with the headaches? Is it still ok to code an E/M with a wellness as long as the additional symptomatic complaint is attached to the E/M? So, it would look like this with the diagnoses:

99395 - Z00.00
99213 - R51

I see that "abnormal findings" are classified to categories R70-R94, so that's why I am assuming that I would attach Z00.00 to the 99395 and NOT Z00.01.

Thanks so much for your input.


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## mitchellde (Sep 29, 2015)

No t his is an exclude 1 note you cannot code symptoms with the well visit.  It is a field 21 edit on the claim.abnormal findings are not expressed symptomatic complaints.  It is an abnormal finding if the provider discovers an issue with a well patient with no presenting complaints.


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## pedscoder21 (Sep 29, 2015)

Ok that does make sense. Thank you again!


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## cubbiecatz (Sep 30, 2015)

According to the guidelines and examples in the ICD10 book, it's acceptable to list other diagnosis codes. Under Chapter 21, section 13 it states that you don't use the Z codes if the exam is for diagnosis of a suspected condition. In such cases the diagnosis code is used.
Pre-existing and chronic conditions and history codes may also be included as additional codes as long as the examination is for administrative purposes and note focused on any particular condition.


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## mitchellde (Sep 30, 2015)

cubbiecatz said:


> According to the guidelines and examples in the ICD10 book, it's acceptable to list other diagnosis codes. Under Chapter 21, section 13 it states that you don't use the Z codes if the exam is for diagnosis of a suspected condition. In such cases the diagnosis code is used.
> Pre-existing and chronic conditions and history codes may also be included as additional codes as long as the examination is for administrative purposes and note focused on any particular condition.


The category however states without complaint, suspected, or reported diagnosis.   So I am not sure if you are saying to add the symptoms or not but the exclude 1 note states that you cannot code signs and symptoms with the Z00 or Z01 codes.


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## pedscoder21 (Sep 30, 2015)

cubbiecatz said:


> According to the guidelines and examples in the ICD10 book, it's acceptable to list other diagnosis codes. Under Chapter 21, section 13 it states that you don't use the Z codes if the exam is for diagnosis of a suspected condition. In such cases the diagnosis code is used.
> Pre-existing and chronic conditions and history codes may also be included as additional codes as long as the examination is for administrative purposes and note focused on any particular condition.



Thanks for your input! That was my thought as well - I'm reading it now and it states, "the Z codes allow for the description of encounters for routine examinations, such as, a general check-up, or, examinations for administrative purposes, such as, a pre-employment physical. The codes are not to be used if the examination is for diagnosis of a suspected condition or for treatment purposes. In such cases the diagnosis code is used. *During a routine exam, should a diagnosis or condition be discovered, it should be coded as an additional code.*"

Although, like Debra said, the Z00- series states, "encounter for general examination without complaint, suspected or reported diagnosis." - So, this is causing confusion...


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## mitchellde (Sep 30, 2015)

The Z00 codes allow for abnormal findings with the code choice for with abnormal findings.  That is not the same as a patient that presents with symptoms.  And as you stated if the patient presents with a problem you cannot use the Z00 codes.
From your post:
The codes are not to be used if the examination is for diagnosis of a suspected condition or for treatment purposes. In such cases the diagnosis code is used. During a routine exam, should a diagnosis or condition be discovered, it should be coded as an additional code."


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## PLewis2014 (Sep 30, 2015)

Pediatricians are asking me about the distinction between the two main ICD-10 codes for well visits/physicals.  Apparently, one reflects a check up with problems discovered and the other without problems discovered.  Do you have a feel for the significance of the difference re: 
?	Reimbursement rate
?	Other issues?
Thank you,
Patricia


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## pedscoder21 (Sep 30, 2015)

mitchellde said:


> The Z00 codes allow for abnormal findings with the code choice for with abnormal findings.  That is not the same as a patient that presents with symptoms.  And as you stated if the patient presents with a problem you cannot use the Z00 codes.
> From your post:
> The codes are not to be used if the examination is for diagnosis of a suspected condition or for treatment purposes. In such cases the diagnosis code is used. During a routine exam, should a diagnosis or condition be discovered, it should be coded as an additional code."



I work for a pediatric practice and quite often our physicians will see children for a well-check and discover a minor issue, such as cerumen impaction. The documentation of the impacted cerumen in the routine well-check exam and listing of the impacted cerumen diagnosis in the A/P does not warrant an additional e/m. They have been coding situations like these as V20.2, 380.4.

Yes, I stated, "the codes are not to be used if the examination is for diagnosis of a suspected condition or for treatment purposes." The exam is _not _for examination of a suspected condition. The encounter was for a routine well-check, not for a complaint, and upon the routine exam a condition was found. So, I feel that now I've read the guideline that states, "during a routine exam, should a diagnosis or condition be discovered, it should be coded as an additional code," you _can _code a diagnosis/condition as a secondary diagnosis to the Z code when the initial purpose of the exam was for a routine health check.


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## cubbiecatz (Sep 30, 2015)

Debra, I am saying add the codes, since that is what the ICD10 guidelines state to do.  Based on the guidelines I interpret the exclude note to coincide with the first example, meaning if a patient came in for a suspected condition, but it came back normal the doctor cannot code this visit with a Z code and report it as a general or normal exam. The doctor has to code it is a problem visit with the signs and symptoms.


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## pedscoder21 (Sep 30, 2015)

I submitted my question to the AAP this morning and they responded with some very helpful documents with examples (obviously, they are related to pediatrics). These examples include coding the pediatric Z codes with diagnoses found upon examination. If anyone would like a copy of them, please post your email and I will forward


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## ollielooya (Sep 30, 2015)

How could one not want this type of info?  I'm not a pediatric coder, but feel this info would be of use to my colleagues who are.

ollielooya@yahoo.com


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## Love Coding! (Oct 1, 2015)

pedscoder21 said:


> Thanks for your input! That was my thought as well - I'm reading it now and it states, "the Z codes allow for the description of encounters for routine examinations, such as, a general check-up, or, examinations for administrative purposes, such as, a pre-employment physical. The codes are not to be used if the examination is for diagnosis of a suspected condition or for treatment purposes. In such cases the diagnosis code is used. *During a routine exam, should a diagnosis or condition be discovered, it should be coded as an additional code.*"
> 
> Although, like Debra said, the Z00- series states, "encounter for general examination without complaint, suspected or reported diagnosis." - So, this is causing confusion...





Persons encountering health services for examinations (Z00-Z13)

Z00.0 - Encounter for general adult medical examination

           Z00.00 - Encounter for general adult examination - without abnormal  findings.

           Z00.01 - Encounter for general adult examination - with abnormal  findings. (Why cannot this code explain an E/M for a problematic diagnosis at the same time as the physicial?)


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## mitchellde (Oct 1, 2015)

Love Coding! said:


> Persons encountering health services for examinations (Z00-Z13)
> 
> Z00.0 - Encounter for general adult medical examination
> 
> ...



Because the exclude 1 notes that an encounter for signs and symptoms are excluded and cannot be coded, you are instructed to code to the signs and symptoms,  an abnormal finding is something not exhibited or suspected, it is discovered by the provider in the course of examining an otherwise a symptomatic patient


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## Love Coding! (Oct 1, 2015)

pedscoder21 said:


> I submitted my question to the AAP this morning and they responded with some very helpful documents with examples (obviously, they are related to pediatrics). These examples include coding the pediatric Z codes with diagnoses found upon examination. If anyone would like a copy of them, please post your email and I will forward



I would like this very much please. 

dshoemaker
dscoder74@yahoo.com


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## Love Coding! (Oct 1, 2015)

mitchellde said:


> Because the exclude 1 notes that an encounter for signs and symptoms are excluded and cannot be coded, you are instructed to code to the signs and symptoms,  an abnormal finding is something not exhibited or suspected, it is discovered by the provider in the course of examining an otherwise a symptomatic patient



Does this also apply to the Peds codes?  Z00.110-Z00.129???  As I do not see the Excludes 1 in this area...thank you


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## mitchellde (Oct 1, 2015)

Love Coding! said:


> Does this also apply to the Peds codes?  Z00.110-Z00.129???  As I do not see the Excludes 1 in this area...thank you



While the exclude one note is at the Z00.0 sub category the category heading for all Z00 codes states without complain, suspected, or reported diagnosis


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## Love Coding! (Oct 1, 2015)

mitchellde said:


> While the exclude one note is at the Z00.0 sub category the category heading for all Z00 codes states without complain, suspected, or reported diagnosis



Thank you so much, it always helps to hear this come from someone else.


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## kelliricks (Oct 1, 2015)

*Same confusion*

I am running into the problem for OB/GYN. When we do an annual and we note that the patient has prolapse or something but we are not doing anything about it at this visit would we code the abnormal findings along with the z code for annual.
 Also if they have abnormal PAP since that is not seen at the visit would that be coded to no abnormalities found because we don't know it is abnormal till two weeks later and we would code the abnormal at the next visit. We typically have our charges out 2 days after the visit. 
Super coder in 2011 said the abnormal pap had nothing to do with the z code chosen. HELP Please.


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## Radcoder86 (Oct 1, 2015)

mitchellde said:


> While the exclude one note is at the Z00.0 sub category the category heading for all Z00 codes states without complain, suspected, or reported diagnosis



I am not seeing that stated in my category heading. It should be right under chapter 21, correct? This is very confusing. Why would the guidelines specifically state you can code chronic conditions with a wellness if that were not the case?


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## mitchellde (Oct 1, 2015)

The guidelines don't state that specifically.  Look at the Z00 category , the category description is part of each individual code descriptions, then right under the Z00.0 subcategory and the Z01 category you will see the exclude 1 note.


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## pedscoder21 (Oct 1, 2015)

Love Coding! said:


> Does this also apply to the Peds codes?  Z00.110-Z00.129???  As I do not see the Excludes 1 in this area...thank you



I asked AAP and according to their response, "It applies to the Z00-0- and the Z00-12- codes do not fall under that Excludes note."

If you look in the book, the excludes note that Debra is referring to is only for the Z00.0- codes, it is not listed with the Z00.12- excludes notes.


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## mitchellde (Oct 1, 2015)

Yes that is correct and I stated that but the category description goes for all Z00 codes and the category states without complaint.


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## Radcoder86 (Oct 1, 2015)

The excludes note is just for encounter for exam of signs and symptoms....that shouldn't apply to chronic conditions.


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## mitchellde (Oct 1, 2015)

Again I refer you to the category description that states without complaint, suspected or reported diagnosis.  The chronic conditions would be the reported diagnosis


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## pedscoder21 (Oct 1, 2015)

mitchellde said:


> Again I refer you to the category description that states without complaint, suspected or reported diagnosis.  The chronic conditions would be the reported diagnosis



I completely understand what you're saying/looking at Debra. But, like Radcoder said, why do the coding guidelines state, _"during a routine exam, should a diagnosis or condition be discovered, it should be coded as an additional code. Pre-existing and chronic conditions and history codes may also be included as additional codes as long as the examination is for administrative purposes and not focused on any particular condition"_

The book also states that "routine examinations" include Z00-

VERY conflicting definitions.


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## Radcoder86 (Oct 1, 2015)

And that category description is what I'm not finding. I'm looking at the note under Chapter 21 and at the excludes notes under the Z00 category, and I don't see that "without complaint, suspected or reported diagnosis" mentioned. Can it be a difference in books? I have an Optum book.


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## dlawler88 (Oct 1, 2015)

Please email me a copy brightpeds@yahoo.com
thanks


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## gunasekarr (Oct 1, 2015)

*Aapc exam result*

Hi, I did my COC exam on past 09/19/2015 still I haven't received result & some of them got a result who did exam on a same date of 09/19/15. But My result is still showing "received" only. So can anyone clarify me??


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## mitchellde (Oct 1, 2015)

Look at the category Z00 it should be in every book.  The category is the key part to every code.  Some books I hav looked at on this one the Z00 is on a previous page from the rest of the category.


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## Radcoder86 (Oct 1, 2015)

Oh gosh, ya I see it now....I feel dumb. I think it's pretty grey though. I interpret that as a complaint or suspected or reported diagnosis from the patient. It's probably best to play it safe though and not code anything with it. Thank you for your help....and patience.


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## pedscoder21 (Oct 1, 2015)

Debra, what are your thoughts on the official coding guidelines that I stated in my last response?


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## mitchellde (Oct 1, 2015)

That is a general statement for administrative Z codes, any one Z Catergory or code can over ride a general statement.  It was not a statement specific to the general wellness codes.
 "during a routine exam, should a diagnosis or condition be discovered, it should be coded as an additional code. Pre-existing and chronic conditions and history codes may also be included as additional codes as long as the examination is for administrative purposes and not focused on any particular condition
Ok the first sentence is consistent with abnormal findings, something that is discovered when examining an asymptomatic payient.
The second statement state they may be added as long as the visit is not focused on any one.  Which is fine except the category states without reported diagnosis,  the preexisting conditions are the rooted diagnosis.  So any one code description will over ride a general guideline


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## RebeccaCross* (Oct 1, 2015)

I'll take a copy!  Thanks!

biller.edewey@gmail.com


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## Radcoder86 (Oct 1, 2015)

Are immunizations going to be able to be administered at wellness visits if it's for preventative?


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## mitchellde (Oct 1, 2015)

Yes you can add the Z23 in fact if you look the Z23 states to code the well visit first.


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## Radcoder86 (Oct 1, 2015)

Okay, I think this is my last question, what about wellness labs? Sometimes they aren't drawn until the patient comes in for their wellness and there are some tests now that are routinely drawn with wellness that aren't covered under the wellness diagnosis. Are we not going to be able to use any other codes for the labs since the exam and labs would all be on the same claim?


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## mitchellde (Oct 1, 2015)

Are they screening, or due to medications the patient is receiving for chronic illness?  If so use the the screening Z codes, and/or the Z51.81 with the Z79 codes for the drug monitoring.


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## Radcoder86 (Oct 1, 2015)

The screening codes are only permitted if we aren't sure whether they have a disorder, correct? So thyroid for instance, if we know they have hypothyroidism and they are on medication, we'd have to use a Z51 & Z79 to run that test with a wellness exam?


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## mitchellde (Oct 1, 2015)

Exactly!


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## Radcoder86 (Oct 1, 2015)

Thank you! All of your help is very appreciated!


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## Radcoder86 (Oct 1, 2015)

I spoke with my supervisor regarding this and she called Optum and they are saying we're still allowed to bill an office visit with PE's in ICD 10?


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## mitchellde (Oct 1, 2015)

I think the codes state different and the excludes is very clear.  If you have an abnormal finding I would agree but only then.


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## pedscoder21 (Oct 2, 2015)

Radcoder86 said:


> I spoke with my supervisor regarding this and she called Optum and they are saying we're still allowed to bill an office visit with PE's in ICD 10?



Yes, CPT is not changing. You can still bill an office visit with a PE, such as 99395 with 99213. Attach the additional diagnoses to the 99213.


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## Radcoder86 (Oct 2, 2015)

So am I completely misunderstanding this whole post? I was under the impression that nothing else can be billed along with a physical unless abnormal findings are found in the exam. So if a patient presents for their physical, but is also complaining of a cough, we would have to code to the signs and symptoms and code a regular office visit for treating the cough, and we would not be able to able to charge for a physical.


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## pedscoder21 (Oct 2, 2015)

Radcoder86 said:


> So am I completely misunderstanding this whole post? I was under the impression that nothing else can be billed along with a physical unless abnormal findings are found in the exam. So if a patient presents for their physical, but is also complaining of a cough, we would have to code to the signs and symptoms and code a regular office visit for treating the cough, and we would not be able to able to charge for a physical.



My original question was regarding ICD codes and when it is appropriate to code chronic conditions or additional diagnoses with well checks.

The debate has been whether or not you can code a well check code (Z00-) with a diagnosis code (and attach both to the well visit 99395). The ICD 10 book states an excludes 1 note under Z00- saying, "encounter for examination of sign or symptom- code to sign or symptom." An adult or child that presents to his/her primary care physician for a well-check is not presenting for an encounter for examination of sign or symptom. If the patient happens to bring up a complaint during the exam, then this complaint should be treated as an additional e/m with the well visit. 

Of course, not all physicians will document enough to warrant an e/m. The coding guidelines state that chronic conditions or additional diagnoses found upon examination of a patient during a routine health exam can be coded as secondary diagnoses. 

Chapter 21 of the ICD 10 book states that _nonspecific _abnormal findings are coded using R70-R94. The Z00- codes do not use the term "nonspecific" (such as Z00.01 encounter for general adult medical examination with abnormal findings), so, any other abnormal findings such as a specific diagnosis like headache can be coded in addition to the Z00.01 code.

Of course, this is my interpretation of the rules and I realize not everyone agrees. I appreciate all of the feedback and would love to hear more!!!!! I wish this was more clear.  

I've been re-reading the ICD-10 book over this for the past couple of days, along with the other coders in my office...this has been quite confusing!

I work in pediatrics, so I submitted my concern to the AAP and they provided me documents stating that yes, you can code chronic conditions and diangoses found upon examination of the patient in addition to the well check Z00.121.


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## Radcoder86 (Oct 2, 2015)

mitchellde said:


> The ICD-10 CM code categories for the general preventive state "without complaint, suspected , or reported diagnosis".  So no I would not code any of the chronic conditions as I consider those to be the other rooted diagnosis.  And if the patient presents with a complaint the you cannot perform the wellness on the same day.



This was the post making me think we can't code an E/M with a PE. Maybe it will just end up being payor specific and will depend on how they interpret the guidelines.


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## pedscoder21 (Oct 2, 2015)

Very true - most likely will be payor specific.


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## mitchellde (Oct 2, 2015)

If the code states excludes 1 then it is not payer specific it is a code directive that you cannot code them together.


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## mitchellde (Oct 2, 2015)

pedscoder21 said:


> My original question was regarding ICD codes and when it is appropriate to code chronic conditions or additional diagnoses with well checks.
> 
> The debate has been whether or not you can code a well check code (Z00-) with a diagnosis code (and attach both to the well visit 99395). The ICD 10 book states an excludes 1 note under Z00- saying, "encounter for examination of sign or symptom- code to sign or symptom." An adult or child that presents to his/her primary care physician for a well-check is not presenting for an encounter for examination of sign or symptom. If the patient happens to bring up a complaint during the exam, then this complaint should be treated as an additional e/m with the well visit.
> 
> ...


A complaint of a headache is not an abnormal finding nor is a presenting symptom of a cough.  Those are signs and symptoms that will be addressed and reschedule the wellness.  An abnormal finding is something discovered by the provider in an otherwise a symptomatic patient.


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## pedscoder21 (Oct 2, 2015)

I was referring to coding an E/M with a well check, not the ICD codes.


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## mitchellde (Oct 2, 2015)

If you cannot code the diagnosis then how can you justify the E&am?


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## Radcoder86 (Oct 2, 2015)

Maybe it just means the symptom codes can't be on the wellness, but they can be on the E/M.


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## pedscoder21 (Oct 2, 2015)

mitchellde said:


> A complaint of a headache is not an abnormal finding nor is a presenting symptom of a cough.  Those are signs and symptoms that will be addressed and reschedule the wellness.  An abnormal finding is something discovered by the provider in an otherwise a symptomatic patient.



Understandable - the physician should bill a well check with an e/m for the headache like they can and do now. 

There is no way providers are going to reschedule a well-check just because the patient happens to say during the well-check, "oh by the way, I have been having headaches, what should I do about this?" That warrants billing an additional e/m.

For a condition found upon routine well-check, like impacted cerumen, the AAP states that this diagnosis can be coded along with Z00.121. The terms noted in Chapter 21 (nonspecific abnormal findings vs. abnormal findings) are confusing and that's where I'm not seeing eye-to-eye


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## pedscoder21 (Oct 2, 2015)

mitchellde said:


> If you cannot code the diagnosis then how can you justify the E&am?



You can code the diagnosis - attach it to the e/m CPT and not with the well-check CPT. Then the diagnosis code would not be in any relation with the Z00- code - like what Radcoder just said.


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## mitchellde (Oct 2, 2015)

pedscoder21 said:


> You can code the diagnosis - attach it to the e/m CPT and not with the well-check CPT. Then the diagnosis code would not be in any relation with the Z00- code - like what Radcoder just said.



You cannot code the symptom with the Z00 in field 21.  The exclude 1 note means these codes cannot be coded together.  This not a linkage issue.


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## mitchellde (Oct 2, 2015)

pedscoder21 said:


> Understandable - the physician should bill a well check with an e/m for the headache like they can and do now.
> 
> There is no way providers are going to reschedule a well-check just because the patient happens to say during the well-check, "oh by the way, I have been having headaches, what should I do about this?" That warrants billing an additional e/m.
> 
> For a condition found upon routine well-check, like impacted cerumen, the AAP states that this diagnosis can be coded along with Z00.121. The terms noted in Chapter 21 (nonspecific abnormal findings vs. abnormal findings) are confusing and that's where I'm not seeing eye-to-eye


Sorry but the exclude 1 note will not allow using a presenting headache with the wellness


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## pedscoder21 (Oct 2, 2015)

mitchellde said:


> Sorry but the exclude 1 note will not allow using a presenting headache with the wellness



Well - with the pediatric codes, that excludes note does not apply. So, maybe it is just for the adult health examinations. Maybe that is why AAP says you _can _code additional signs/symptoms/diagnoses with the pediatric Z00.121. 

I'm left wondering how CPT would handle this...can't code 99395 with 99213 anymore? Because there would be an additional diagnosis with the Z00- code. It just doesn't make sense. Does anyone else find this odd??


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## mitchellde (Oct 2, 2015)

pedscoder21 said:


> Well - with the pediatric codes, that excludes note does not apply. So, maybe it is just for the adult health examinations. Maybe that is why AAP says you _can _code additional signs/symptoms/diagnoses with the pediatric Z00.121.
> 
> I'm left wondering how CPT would handle this...can't code 99395 with 99213 anymore? Because there would be an additional diagnosis with the Z00- code. It just doesn't make sense. Does anyone else find this odd??



While the exclude one note may not be repeated for the well child sub categories they are still a part of the Z00 category with dates encounter for general exam WITHOUT complaint , suspected, or reported diagnosis


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## LR Griffin (Oct 2, 2015)

pedscoder21, 
I too would love the AAP information you recieved.  I am a Pediatric coder also and have typically billed for Preventive and Office Visit charges on the same day prior to 10/01. My practice is associated with a Medical Univerisity and Children's Hospital with a significant percentage of patients being chronicly troubled w/ large range of medical issues. Many are not "Well" at their preventive visits.  There Patients typically require allot of time over and above a standard preventive visit. There should be allowances for that ( in my opinion anyway).  email address below.

lgriffin2@gru.edu


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## Radcoder86 (Oct 2, 2015)

Okay Debra, so if someone comes in for wellness and they have hyperlipidemia as a chronic condition, but in the note it states that their LDL has risen significantly (reviewing labs for wellness), do I code that as abnormal findings?


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## Rfoster (Oct 5, 2015)

*would like AAPC info emailed also*

pedscoder21,
If you'd be so kind to forward that info to me as well I would greatly appreciate it.  I also am a pediatric coder and this is a scenario we seem often.  I've told our provider the new "rules" of split billing but there are still
a lot of questions we are having .  Can you please forward your info from AAPC to RBoswell@intpeds.com.
Please and thank you so much!
Rachel


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## mitchellde (Oct 5, 2015)

Radcoder86 said:


> Okay Debra, so if someone comes in for wellness and they have hyperlipidemia as a chronic condition, but in the note it states that their LDL has risen significantly (reviewing labs for wellness), do I code that as abnormal findings?



Yes if documented by the provider as a finding requiring attention.


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## jojo.garcia1988@gmail.com (Oct 6, 2015)

@pedscoder21

thanks for sharing this.. please send the docs to my email.. 

jgarcia@ushealthmark.com


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## pedscoder21 (Oct 6, 2015)

http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_049298.hcsp?dDocName=bok1_049298

This AHIMA article states that additional diagnosis codes are allowed with the Z00- codes (so long as the intent of the encounter was for a routine exam, not for a symptom/diagnosis/etc). Example that they give:
*
"45-year-old established patient presented to her physician's office for a routine physical exam. During the examination the physician identified an enlarged thyroid. The physician ordered a laboratory test and requested to see the patient in two weeks."

First listed dx: Z00.01 - encounter for general adult medical examination with abnormal findings
Additional dx: 240.9 - goiter, unspecified*


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## mitchellde (Oct 6, 2015)

Yes with abnormal findings, I never indicated otherwise.  However you may not code symptoms with a preventive.


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## pedscoder21 (Oct 6, 2015)

Thanks again for your input Debra, this has been a confusing topic 

I posted that article to share some additional info out there on coding well-checks.


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## tcan618 (Oct 30, 2015)

Hello, I have a question. We have a patient that came in for a scheduled routine exam, but he/she also has 3 or so chronic dx's that were addressed during this visit. The doctor documented dx's were unchanged, or unchanged with medication changes. The doctor is billing for both a preventive exam w/dx z00.00 and also a 99214 w/medical dxs.
This is a medicare pt, so after he did the Medicare AW exam, he continued to do the entire ROS and Exam. Any thoughts on this??? Thank you!


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## thelton (Oct 30, 2015)

There is an article in the October 12, 2015 Part B News that addresses the problem visit with a preventive visit.  Basically, it states that you can still bill a problem visit on the same day as a preventive visit.


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## pedscoder21 (Oct 30, 2015)

Would you be able to send me a link to view this article? Thank you


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## d_imparato (Oct 30, 2015)

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I submitted my question to the AAP this morning and they responded with some very helpful documents with examples (obviously, they are related to pediatrics). These examples include coding the pediatric Z codes with diagnoses found upon examination. If anyone would like a copy of them, please post your email and I will forward  
__________________


I code for a multi-specialty clinic with Pediatrics as a specialty.  Could you please send me the information as well??  ladonnaimparato@yahoo.com

Thank you in advance!
Donna, CPC, AAS


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## pedscoder21 (Oct 30, 2015)

Sure - I just sent them


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## tmcquegge (Nov 2, 2015)

*send to me please*

tmcquegge@jpmpsc.com


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## mitchellde (Nov 2, 2015)

thelton said:


> There is an article in the October 12, 2015 Part B News that addresses the problem visit with a preventive visit.  Basically, it states that you can still bill a problem visit on the same day as a preventive visit.



Only if it is an abnormal finding.  You cannot bill a presenting sign or symptom at the same time as the wellness.  The ICD10 CM conventions are really very clear on this. It is an exclude 1 convention and the Catergory descrption clearly states without complaint.  A presenting complaint is not an abnormal finding.


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## jbuelto (Nov 2, 2015)

Received this as part of the questions coming up since the icd 10 switch..
?Don?t overthink the changes
?Many CPT coding questions have come up as a result of the change
?CPT coding and reimbursement policies based on CPT remain the same
?Focus on the basics: location, laterality, clinical details
General medical exam
?The CPT rules are not changed with the implementation of ICD-10. The rules for billing a ?sick visit? on the same day as a ?preventive visit? require:
?Significant and separately identifiable services (documentation of the sick visit) was performed on the same day as the physical. If both are 1) medically necessary and 2) documented separately, no ?double dipping,? then add Modifier -25 to the Evaluation and Management Code (reporting the ?sick visit? with 99201-99205 or 99211-99215).

I think the wording was confusing...but in Leigh-mans terms:
excludes 1: Encounter for EXAMINATION of signs and symptoms code to signs and symptoms... so if you are examining a patient for signs or symptoms use the 99201-99215 codes.. which would be separate and identifiable from the well visit...


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## mitchellde (Nov 2, 2015)

jbuelto said:


> Received this as part of the questions coming up since the icd 10 switch..
> ?Don?t overthink the changes
> ?Many CPT coding questions have come up as a result of the change
> ?CPT coding and reimbursement policies based on CPT remain the same
> ...


The excludes 1 note means you cannot code them together.  You cannot code the Z00.00 with a symptom.  The category Z00 states without complaint.  You really cannot justify a sick patient presenting for symptoms and a well visit.  This has nothing to do with the use of the 25 modifier. It is the diagnosis codes category definition and the exclude1 definition.  CPT rules and usage instruction cannot address this issue.


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## jbuelto (Nov 2, 2015)

I see this post growing so I just shared what I received in a follow up icd 10 questionaire...

excludes 1: Encounter for EXAMINATION of signs and symptoms --*"code to signs and symptoms"* perhaps if ONLY was there I would agree with you...

So technically yes, you are right.. Z00.00 will go with 9939* and separately my knee pain which was discussed in detail with an xray ordered can go to a 99213-25...they are not together, they are separate...


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## anne32 (Nov 2, 2015)

The general guidelines do not even support what you are saying in your post. The general guidelines say "The codes are not to be used if the examination is for diagnosis of a suspected condition or for treatment purposes. In such cases, the diagnosis is used."  I understand you are saying the codes are separate- the Z code is for the physical and then the problem is with an E/M. The general guidelines go on to say "Pre-existing and chronic conditions and history codes may also be included as additional codes _as long as the examination is for administrative purposes and not focused on any particular condition._" So basically certain other codes can be added as long as the exam is not focused on treating the condition or a main focus of the exam.


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## jbuelto (Nov 2, 2015)

Payments are based on CPT codes, So are you saying they are wrong in providing information stating otherwise? I'm just asking so that I can make them aware of their error...

Thank you!


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## jbuelto (Nov 2, 2015)

anne32 said:


> The general guidelines do not even support what you are saying in your post. The general guidelines say "The codes are not to be used if the examination is for diagnosis of a suspected condition or for treatment purposes. In such cases, the diagnosis is used."  I understand you are saying the codes are separate- the Z code is for the physical and then the problem is with an E/M. The general guidelines go on to say "Pre-existing and chronic conditions and history codes may also be included as additional codes _as long as the examination is for administrative purposes and not focused on any particular condition._" So basically certain other codes can be added as long as the exam is not focused on treating the condition or a main focus of the exam.



and these guidelines are not new.. they also applied to ICD 9 guidelines which is why it's makes it all the more confusing...


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## mitchellde (Nov 2, 2015)

The excludes 1 note does not mean that you link the codes to separate encounters, it means they cannot be coded together.  That means at the same encounter.  Just because CPT rules state it is acceptable to code a preventive with an office visit as long as you use a 25 modifier, does not mean you can over ride ICD-10 conventions in order to get it done.  
This has been one of the most difficult concepts to get across, but it is an ICD-10 CM issue and it does change things.


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## thelton (Nov 3, 2015)

There is an article in the October 12, 2015 Part B News which addresses the issue of a problem visit billed on the same day as a preventive service which states you can bill both visits.  There are several industry experts quoted in the article and they helped clear up any confusion in my mind about this issue.


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## pedscoder21 (Nov 3, 2015)

thelton said:


> There is an article in the October 12, 2015 Part B News which addresses the issue of a problem visit billed on the same day as a preventive service which states you can bill both visits.  There are several industry experts quoted in the article and they helped clear up any confusion in my mind about this issue.



I wish I had access to this but our office doesn't have a subscription  is there any other way to get access to these articles? (I'm guessing not).


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## mitchellde (Nov 3, 2015)

No there is no way to acess these without a subscription, but they are very careful in the wording.  It does not state that you can bill a symptomatic patient with a well visit.  It only addresses the issue of billing a preventive CPT code with an office visit.  CPT instruction do state you can do this.  However at no time does the article state that you can bill a symptomatic diagnosis with a visit for preventive.


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## thelton (Nov 3, 2015)

I respectively disagree with the above statement.  The Part B News article quotes at least 3 industry experts who state the excludes note does not exclude billing a problem visit on the same day as a preventive visit.  The title of the article is "ICD-10 Z-codes don't mean you can't bill preventive, problem services together".  That seems pretty straightforward to me.


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## mitchellde (Nov 3, 2015)

I am not seeing how they say that ;  the excludes 1 note says encounters forsigns and symptoms are purely excluded,  and that is what a problem visit is.  So you are saying we are to ignor the ICD-10 CM conventions and just code what you want.  Then where does it end?  At what point do the rules/guidelines/conventions mean anything?   I will continue to voice my objections to this line of thinking and state that the excludes 1 is extremely clear in this and you cannot code them together.


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## jbuelto (Nov 4, 2015)

AAPC - Healthcare Business Monthly
see example page 25

https://aapcperfect.s3.amazonaws.co...f7b3/76a8bc04-f804-4725-9292-f4901df88218.pdf


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## mitchellde (Nov 4, 2015)

The article is about the proper use of a 25 modifier and the writer used a bad and incorrect example. I am going to contact the AAPC regarding this error.


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## JDELINA (Nov 6, 2015)

DI2 said:


> --------------------------------------------------------------------------------
> 
> I submitted my question to the AAP this morning and they responded with some very helpful documents with examples (obviously, they are related to pediatrics). These examples include coding the pediatric Z codes with diagnoses found upon examination. If anyone would like a copy of them, please post your email and I will forward
> __________________
> ...


can you send me a copy too....pls e mail to vchc4117@yahoo.com


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## JDELINA (Nov 6, 2015)

can i bill a well visit exam and E/M , E/M because of pt pre existing condition


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## ollielooya (Nov 9, 2015)

Debra, have you yet received a reply to your question to AAPC about the example furnished in Healthcare Business Monthly?  I've been waiting to be bombarded from our physicians with the questions similar to the one that started this thread, and it happened today.  I'm preparing a response, but have realized that this will continue to be a mis-understood topic and interpreted and misinterpreted in various ways.  I think I understand it now, but only after much study and musing on my part.  My old brain has been having difficulty emerging from the maze and haze!  It just seems easy to inform the physicians that rescheduling the patient for their preventive visit separate from the problem-focused visit would be the way to go, albeit not a popular solution for the patient in regards to convenience. Also this issue that this thread addresses is just another reason why administrative billing/coding folk can't assume that just because "this is the way we've always done it" would  be applicable to what's being required now! 
Anyway, eager to see your continued input to this thread and what you hear from AAPC.


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## CodingKing (Nov 10, 2015)

Let's pretend you can still bill both. The key word is significant. Thinking of my own annual physicals and seeing some appeals from patients who feel their physician is inappropriately billing both. 90% of the time the definition of significant is not met. Just because you address a preexisting medical condition does not mean the work  done to address it was significantly over and above what is included in a preventive visit.


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## ollielooya (Nov 11, 2015)

True, when we're dealing with the use of Modifier 25.  If "significant" the issue addressed would have to be able to stand alone based on the chart notes. I know if this is brought up during one of our chapter coding meetings, it will be a "hot" topic and the arguments will ensue based on what we've already read here. I'm taking the conservative approach here and advising our doctors to shore up their policies on this to their patients and if possible to schedule the preventives separate from the EM problem focussed visits.


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## GMN9046 (Feb 25, 2016)

pedscoder21 said:


> I submitted my question to the AAP this morning and they responded with some very helpful documents with examples (obviously, they are related to pediatrics). These examples include coding the pediatric Z codes with diagnoses found upon examination. If anyone would like a copy of them, please post your email and I will forward



gnunez1971.gn@gmail.com


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