CODING & DOCUMENTATION

 

Fam Pract Manag. 2022 Jan-Feb;29(1):32.

Author disclosure: no relevant financial relationships.

PROBLEM NOT ADDRESSED UNTIL FOLLOW-UP VISIT

Q

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?

A

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

Q

Can we report an annual wellness visit (AWV) incident-to a physician when clinical staff provide the AWV?

A

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

ABOUT THE AUTHOR

Cindy Hughes is an independent consulting editor based in El Dorado, Kan., and a contributing editor to FPM.

Author disclosure: no relevant financial relationships.

WE WANT TO HEAR FROM YOU

Send questions and comments to fpmedit@aafp.org, or add your comments below. While this department attempts to provide accurate information, some payers may not accept the advice given. Refer to the current CPT and ICD-10 coding manuals and payer policies.

 
 

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