EM Coding Alert

Question: The physician saw a 39-year-old established male patient for an annual checkup. During the checkup, the physician noted that the patient was persistently coughing. The patient said he has had this persistent productive cough for the past week or so, and it has been fluctuating in intensity. The physician performed a detailed examination of the patient's respiratory and cardiovascular systems. Based on the history, signs and symptoms, and observations during the exam, the physician arrived at the diagnosis of acute bronchitis. He prescribed medication for the problem and called for a review after a week. He also completed the other aspects of the annual checkup. Can we report a problem-oriented E/M service in addition to the preventive medicine code?

South Dakota Subscriber

Answer: Yes. In this case, the physician uncovered that the patient had a persistent cough. He then performed a detailed exam of the respiratory and cardiovascular systems. He made the diagnosis of acute bronchitis and prescribed medication for the same.

Since the patient had a problem the physician evaluated and managed, over and above the elements of the wellness visit, you can report an additional evaluation and management (E/M) service like 99214 (Office or other outpatient visit for the evaluation and management of an established patient...) because the patient is established. You will then append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code you are reporting. You will report the annual checkup with 99395 (Periodic comprehensive preventive medicine reevaluation and management of an individual... established patient; 18-39 years) because the patient is established and in the age group between 18-39 years.

Remember: When you are reporting a problem-oriented E/M service in addition to a preventive medicine code, you will have to report separate diagnosis codes for the preventive medicine code and the other E/M service. If you do not support the E/M service with appropriate diagnosis codes along with required documentation, your claim for the E/M service will be rejected.

In this case, you will report Z00.01 (Encounter for general adult medical examination with abnormal findings) to support the preventive medicine code you are reporting. Since ICD-10 advises you to use an additional code to identify the abnormal findings, you will also append J20.9 (Acute bronchitis, unspecified) to the preventive medicine code after Z00.01. In addition, you will report J20.9 with the problem-oriented E/M code.