Primary Care Coding Alert

Question: What is the appropriate way to bill for an outpatient visit when the patient comes in without a complaint? Our provider performed a brief history on the patient, did an extended exam, and ordered a flu shot. As the patient did not come in for an evaluation and management (E/M) visit or for a preventive exam, what codes can we use? And would it be appropriate to use Z23 as a primary diagnosis?

Codify Subscriber

Answer: How you report the encounter will depend on what was done for the patient and why.

If the provider ordered a flu shot that was not provided at the encounter, then you are left to report the visit using only an appropriate evaluation and management (E/M) service. Whether that E/M service is problem-oriented or preventive, in turn, will depend on why the provider performed the brief history and extended exam.

Did the patient have signs or symptoms that led the provider to do the history and exam, even though the patient did not nominally have "a complaint?" If so, then reporting a problem-oriented E/M code is appropriate, and any diagnosis reported should reflect the signs and symptoms in question.

If the provider simply performed the history and exam to ensure a flu shot was not contra-indicated, a low-level problem-oriented E/M code (e.g. 99201 or 99211) may also be appropriate.

Did the provider take advantage of the patient's presence in the office to perform the history and exam associated with a preventive medicine visit? Then, the appropriate preventive E/M should be reported with a corresponding diagnosis of Z00.00 (Encounter for general adult medical examination without abnormal findings) if this is an adult patient.

If the patient received the flu shot ordered, then you should report the immunization and its administration using the appropriate codes for each. This may be in addition to an E/M code if the E/M service was significant and separately identifiable from the administration of the immunization.

The diagnosis code(s) for the immunization and its administration depends on the age of your patient. A note under Z23 (Encounter for immunization) tells you to "code first any routine childhood examination." This means that Z23 is not an acceptable primary diagnosis for a child in this scenario, and you would have to provide the appropriate code from Z00.12- (Encounter for routine child health examination) as the principal diagnosis.

If your patient is an adult, however, Z23 is a perfectly acceptable primary diagnosis in this particular situation.

Because of the uncertainty regarding why the patient presented to your office and why the provider did the history and extended exam you referenced, it would be useful to talk with the provider to further clarify the actual service provided and the reasons for it.