Primary Care Coding Alert

And don’t forget to tell the full story with additional encounter codes.

A provider meets with an established patient who has a family history of breast and ovarian cancer. The patient has already undergone testing, and at the visit, the physician reviews the genetic results and other risk factors, then offers recommendations for the patient, such as breast magnetic resonance imaging (MRI)s and early colonoscopies, as a part of a cancer prevention plan.

Before you decide how you would code this encounter, take a look at the way one practice handled the claim and see if you agree or disagree with the way they reported it. Then, read on to see if you agree or disagree with our experts’ analysis of this case study.

Here’s the Practice’s Original Claim

The practice billed an office visit and a preventive service code as the visit combined both medical diagnostics and preventive counseling. The office used Z codes for the primary diagnosis, and the whole claim was sent as follows:

• 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity …)
• 99401 (Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes)
• Z80.41 (Family history of malignant neoplasm of ovary)
• Z80.3 (Family history of malignant neoplasm of breast).

Later, the practice received a response from the payor that the Z80.41 or Z80.3 diagnosis indicated were inconsistent with the services billed, specifically that the claim only offered one diagnosis for both the 99213 and 99402 billed on the same date. The payer indicated that the 99213 must have a separate problem-focused diagnosis indicated besides the Z code as a component of the established patient visit. The payor’s perspective was that everything seemed to be covered under the preventive visit code.

So, who is right in this case? Can the provider bill for an established patient sick visit and a preventive/risk factor service? And can that be done using both Z codes? Or is the payer correct in denying the claim based on its position that the 99213 lacks a problem-focused diagnosis?

Documenting Sick and Preventive Services Together

The scenario points to a perennial coding problem: can a provider bill for a sick visit and a preventive/risk-factor service when it is provided during the same encounter?

The short, simple answer is “yes.” But there are some important criteria that have to be met in order for you to be able to bill the two services together.

If the counseling is related to the reason for the visit (for example, the patient is experiencing medical problems related to a cancer diagnosis), then the counseling is regarded as part the counseling/coordination of care inherent to the visit, and you would only report the evaluation and management (E/M) service — in this case, 99213.

However, if the patient is experiencing cancer-related problems treated during the encounter and the provider discusses other preventive or risk factor reduction issues unrelated to the patient’s treatment (e.g. diet and exercise to maintain a healthy weight), you can consider reporting the counseling with the appropriate preventive medicine counseling code from 99401-99404 in addition to the problem-oriented E/M visit. You would do this by appending 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 problem-oriented E/M code to indicate it was a significant, separately identifiable service from the preventive medicine counseling.

No Presenting Problem, No Problem-Oriented E/M

“In this case, even though one could argue some history might have been involved, there is no presenting problem, no exam, and no medical decision making. The counseling relates to risk factors and preventive recommendations, rather than diagnosis and/or treatment,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

This is supported by the choice of diagnosis codes. Even though ICD-10-CM guidelines state that “Z codes may be used as first-listed [principal diagnosis code in the inpatient setting] or secondary code, depending on the circumstances of the encounter,” “Z80.41 and Z80.3 describe family history, not a current problem attributable to the patient,” Moore notes.

So, “because the patient was not seen for anything else besides the genetic counseling, a 99213 was not warranted,” adds Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California.

Paint a Bigger Picture With More Z Codes

Finally, our experts suggested that the claim could have been better illustrated with additional Z codes. “In addition to the Z80.41 and Z80.3, I would have coded Z13.79 [Encounter for other screening for genetic and chromosomal anomalies]” says Johnson. Additionally, “you could also append one or more of the following to reflect the nature of the counseling provided,” says Moore:

• Z71.2 (Person consulting for explanation of examination or test findings)
• Z71.83 (Encounter for nonprocreative genetic counseling)
• Z71.89 (Other specified counseling).