Wiki Normal vs. Abnormal Exam

[bsteinagel]

Hello,

This is my first post on the AAPC forum. I've reviewed the ICD-10 coding guidelines as well as information regarding coding for pediatric preventive care from the AAP. I can't find a clear cut answer to my question. Does an abnormal finding have to be something that's found on the physical exam portion of a well visit in order to qualify as an abnormal exam?

Example: New patient comes in for a well child exam. The patient has a history of ADHD for multiple years.
Would this be an abnormal exam or a normal one? The guidelines state to base your decision of abnormal vs normal off what is known at the time of the visit. In this scenario, the patient is new and the provider did not know the patient had ADHD until he was informed during the visit. Let's assume the ADHD is a chronic, stable condition. There is evidence to support either scenario:

Evidence for a Normal Exam
The ADHD is an existing chronic condition that is stable. It is not an abnormal finding on the physical exam itself.

Evidence for an Abnormal Exam
The ADHD diagnosis is new to the provider and the provider did not know about it until he/she was informed during the well child visit. Even though it's a chronic condition that is stable it was not known at the time of the visit.

What's the verdict? The guidelines don't specifically say it has to be a finding on the physical exam portion of the visit itself. This seems to be a loophole in the guidelines.

I know the topic of normal vs abnormal exams has been answered ad-nauseum on the forum, but I've not seen any answers that specifically address this issue. Thank you for taking the time to answer.

 

[rthomas@impcna.com]

This is how we handle in our clinic:
New patient comes in for a well child exam. The patient has a history of ADHD for multiple years. - We would do an abnormal then schedule patient to come back in a week later for ADHD evaluation or follow up (this depends on when the patient last had an rx filled) and ask the parent to have the Vanderbilt forms completed by teachers & parent.

If the provider already treats the patient for ADHD and is stable we use normal exam. The ADHD is a chronic diagnosis and is considered normal for the patient.

If the provider already treats the patient for ADHD and the patient isn't stable and needs medication adjustments we use abnormal exam. Some insurances allow a wellness visit and office visit be billed on the same day as long as the providers documentation supports it. If the patient that has an insurance that doesn't allow a wellness visit and office visit be billed on the same day the provider will change the visit to an ADHD follow up and have them to come back for their wellness exam at a later time.

Hope this helps.

 

[bsteinagel]

rthomas, thank you for the response it was very helpful in answering my question.

This is how we handle in our clinic:
New patient comes in for a well child exam. The patient has a history of ADHD for multiple years. - We would do an abnormal then schedule patient to come back in a week later for ADHD evaluation or follow up (this depends on when the patient last had an rx filled) and ask the parent to have the Vanderbilt forms completed by teachers & parent.

If the provider already treats the patient for ADHD and is stable we use normal exam. The ADHD is a chronic diagnosis and is considered normal for the patient.

If the provider already treats the patient for ADHD and the patient isn't stable and needs medication adjustments we use abnormal exam. Some insurances allow a wellness visit and office visit be billed on the same day as long as the providers documentation supports it. If the patient that has an insurance that doesn't allow a wellness visit and office visit be billed on the same day the provider will change the visit to an ADHD follow up and have them to come back for their wellness exam at a later time.

Hope this helps.

Thank you for taking the time to answer my question. This was very helpful.

Brad