Primary Care Coding Alert

Question: We have a Medicare patient who has a history of swelling during travel, and while traveling, the patient experienced persistent bilateral swelling in her lower extremities. She had been prescribed furosemide (Lasix) by an out-of-state physician and came to our provider for a medication refill. Our provider billed 99213 with a diagnosis of Z87.898, but Medicare denied the claim.

How should we rebill this?

AAPC Forum Subscriber

Answer: The problem with billing this encounter using Z87.898 (Personal history of other specified conditions) is that the diagnosis says the patient has a history of a specified condition, but it does not convey what that specific condition is or whether the patient still has it. As such, by itself, the code does not justify the medical necessity of a problem-oriented evaluation and management service like 99213, from a Medicare perspective.

So, along with the 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making….) and the Z87.898, you need to specify the “other” condition. Depending on your provider’s judgement, that could be R22.43 (Localized swelling, mass and lump, lower limb, bilateral).