Primary Care Coding Alert
Watch for EHR Quirks When Reporting Dx Codes
Question: It looks like my providers recently started selecting their own ICD-10 codes. They are selecting screening codes, such as Z12.31 and Z12.11 as diagnosis codes with their evaluation and management (E/M) visits when they order the tests. These are tests that will be done at external facilities at a later date. We do not perform these in the office. Should we be reporting these codes? AAPC Forum Participant Answer: No. Report screening codes such as Z12.31 (Encounter for screening mammogram for malignant neoplasm of breast) and Z12.11 (Encounter for screening for malignant neoplasm of colon) when the screenings themselves are the reason for the encounter, not during the E/M encounter when the provider decides to order it. EHR alert: Many electronic health record (EHR) systems will automatically pull any diagnoses that were used during the encounter and place them into the assessment and plan (A/P) sections of the medical record. This includes screening codes or other diagnoses that will be used for future labs. Systems might also suggest codes when a provider is filling out the record. This can lead to providers selecting inappropriate codes if they aren’t educated on guidelines or proper usage. Be sure to keep a line of communication open and query your provider if ever you have questions.
Related Articles
Primary Care Coding Alert
- News You Can Use:
Look to New ICD-10 Codes to Report Abuse, Neglect, and SDoH
Plus: See how financial difficulty is incorporated into several new codes. Starting April 1, 2023, [...] - Mythbusters:
Bust These Myths to Avoid Injection Rejection
Hint: Gain some insight on medical necessity, too. Injection encounters are easy to miscode for [...] - Practice Management:
Turn Your Basic Audit Program into a Strong One With These Tips
Discover how audit type can influence the kind of sample you use. With the COVID-19 [...] - You Be the Coder:
No Cauterization? No Problem for This Nose-Bleed Scenario
Question: How can I report epistaxis treatment when the provider didn’t perform cauterization or packing? Maine [...] - Reader Questions:
Clear Up Confusion About Leveling Using Time
Question: One of our providers wants to bill an evaluation and management (E/M) visit using time, [...] - Reader Questions:
Watch for EHR Quirks When Reporting Dx Codes
Question: It looks like my providers recently started selecting their own ICD-10 codes. They are selecting [...]
