PROBLEM NOT ADDRESSED UNTIL FOLLOW-UP VISIT
I found a problem during a new patient's preventive medicine visit, but the patient wanted to return for a follow-up visit to have the problem evaluated. Because I did not perform a separate E/M service for the problem, should I report the diagnosis code for the preventive medicine visit with or without abnormal findings?
Report the appropriate ICD-10 code for a routine health examination with abnormal findings (e.g., Z00.01, “Encounter for general adult medical examination with abnormal findings”) and a code for the abnormal findings. When a new, not controlled, or worsening problem is identified during a preventive medicine visit you should always report a code that includes “with abnormal findings.” For diagnosis coding, there is no requirement that the problem be addressed during the encounter. Rather, the intent is to show that the preventive medicine service resulted in abnormal findings. A separate E/M service for addressing the problem would be reported when it is performed.
INCIDENT-TO ANNUAL WELLNESS VISITS
Can we report an annual wellness visit (AWV) incident-to a physician when clinical staff provide the AWV?
No. Incident-to does not apply to services with their own benefit category, such as AWVs and initial preventive physical examinations. However, physicians and other qualified health care professionals (e.g., clinical nurse specialists and physician assistants) who may directly provide the AWV may also supervise other health professionals such as nurses, dietitians, or health educators as they provide the AWV, and then bill for the service. When a team (e.g., physician and medical assistant) provides the service, all team members must work within the scope of their training and licensure in compliance with state regulations. Check your Medicare administrative contractor's guidance about which clinical staff may provide the AWV. Some contractors do not allow medical assistants to do it.
TREATING SECOND-DEGREE BURNS
What is the appropriate code to report for providing follow-up care for a small second-degree burn of the forearm that requires debridement and dressing change in the office? Would an E/M code be appropriate?
Report CPT code 16020, “Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area).” Only report an E/M service when a significant and separately identifiable service is clinically indicated. In those cases, append modifier 25 to the E/M code.
DIAGNOSIS CODES FOR INFANT WITH PROBLEM RULED OUT DURING VISIT
What diagnosis codes should I assign when new parents bring in an infant because they're concerned about a potential problem that is ruled out at the visit?
If any symptoms (e.g., rash) prompted the visit, report codes for the symptoms. However, when parents are concerned about normal newborn behaviors (e.g., they suspect apnea in a neonate who is breathing normally), assign codes in category Z05 (e.g., Z05.3, “Observation and evaluation of newborn for suspected respiratory condition ruled out”) to indicate the reason for the visit. These codes are applicable only to babies in the first 28 days of life. For older infants and children, codes in categories Z03 and Z04 are useful for reporting suspected conditions or suspected injuries ruled out after examination. Category Z20, “Contact with and (suspected) exposure to communicable diseases,” and Z77, “Other contact with and (suspected) exposures hazardous to health,” are useful for visits when a suspected condition due to exposure is ruled out. One code that may appear appropriate but typically is not is code Z71.1, “Person with feared health complaint in whom no diagnosis is made.” That code may be interpreted as an encounter that did not require the physician's observation and examination.
