The answer provided below is from the Washington State Medical Association Practice Resource Center:
It is important to remember that there are different rules for different code sets. Per CPT, you can bill an office visit and a Preventive on the same day if you meet the criteria to use Modifier 25. This also applies when billing an office visit in conjunction with a minor procedure. If the office visit is significantly identifiable and goes above and beyond what is required for the other procedure or visit you can bill for both services. Again the rules for this tend to be payer specific and depend on if other services are billing.
The AAPC issue, that Debra is referring to, is more complicated. Technically under ICD-10 there is a Type 1 Excludes under Z00.0 (Base Preventive DX) that states you should not code a sign or symptom with a preventive service. The issue is how this rule is being interpreted. Some, like the contributor to the AAPC forum, think this means you cannot bill an additional office visit with the preventive. There are other coder and organizations that disagree with this interpretation because the implementation of ICD-10 was not suppose to change the way we fundamentally billed services before the implementation. This interpretation would have huge financial problems for practice across the country and the general consensus is that this interpretation only applies in certain clinical scenarios. It depends on the situation as well as the documentation. See below.
? If the reason of the visit is for evaluation of a sign or symptom then you would simply assign the sign or symptom code and not the general exam code. So it is important to have clear documentation as the what the patient was coming in for at the time of service a well child or to have a problem accessed.
? If a patient comes in for a preventive exam and half way through the visit says "Oh, by the way....", then the physician can address that problem specifically outside of the routine exam (provided they have time and is something they can do) and code for the preventive exam and an E&M as long as the documentation for the E&M is separate. They must also include modifier 25 with the E&M code.
? If the patient comes in for their preventive exam and then complains of an acute condition that needs to be addressed, then that would supersede the preventative exam which would be rescheduled. And, of course, if the patient has a sign/symptom that needs to be addressed by a specialist, then the physician could give a referral and would code the preventative exam.
From a coding perspective, there is nothing that states that a provider cannot code for a Preventative exam and an E&M on the same day, same claim. So my interpretation that seems to be playing out with payers is that the excludes note wouldn't apply if the diagnosis for the preventative exam CPT is separate from the diagnosis for the E&M CPT. Just as if a physician bills for an office visit and a minor procedure on the same day, each CPT code can carry a unique diagnosis. The diagnosis pointer on the claim would link the Z00.00 to the CPT for the preventative exam and then another pointer links the E&M CPT to the sign/symptom or condition. The use of Modifier 25 would trigger the E&M as a separately identifiable E&M so the Excludes note isn't applicable.
