Primary Care Coding Alert

Question: A patient came into our practice saying he thought he might have a hernia. Our provider examined him and determined the patient did not have the condition. Can we bill for an evaluation and management (E/M) service in this encounter and, if so, should we use Z00.00 or K40.90 as a diagnosis code with the E/M?

Kansas Subscriber

Answer: When a patient presents with a suspected problem and undergoes an examination, you should bill the appropriate E/M visit code from 99201-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …) even if no problem was found, providing you have documented the necessary history and physical exam to support your provider’s medical decision making (MDM).

For a diagnosis code, you cannot use a code such as K40.90 (Unilateral inguinal hernia, without obstruction or gangrene, not specified as recurrent), as ICD-10 guideline IV.H instructs you not to code “diagnoses documented as ‘probable,’ … ‘rule out,’ … or other similar terms indicating uncertainty.”

Instead, you would use an encounter code to justify the E/M. In this case, you would not use Z00.00 (Encounter for general adult medical examination without abnormal findings) as this code is used when the patient is asymptomatic or is presenting with no specific complaint or problem. As the patient did present with a complaint, you would use Z71.1 (Person with feared health complaint in whom no diagnosis is made) to indicate your provider found no medical problem after examining the patient.