Preventive  and  E/M coding: What diagnoses go where?

Q: One of our patients came in for an annual checkup with diagnoses of hypertension and diabetes. A yearly exam was done and the chronic conditions were managed.
Under ICD-10 rules, is this visit to be coded Z00.00
(Annual with no abnormalities) since nothing new was found during the annual exam, or Z00.01 (Annual with abnormalities) since the patient has the chronic diseases? 

A: Z00.00 (Encounter for general adult medical examination without abnormal findings) would be appropriate since there are no new findings at the visit. You should also bill the chronic stable conditions (i.e., hypertension and diabetes) along with the Z00.00.

Q:  We have a patient who needed a pre-op clearance prior to a major surgery, and an EKG was ordered.  The EKG showed that the patient has a right bundle branch block. What diagnoses do I use when I bill the EKG?

A: The guidelines state that:

• An insignificant or trivial problem/abnormality that is encountered in the process of performing the preventive medicine evaluation and management service and that does not require additional work and the performance of the key components of a problem-oriented E/M service should not be reported.

• If an abnormality is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem or abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate Office/Outpatient code should also be reported. Modifier 25 should be added to the Office/Outpatient code. 

• When a new patient presents for problem oriented Evaluation and Management service in conjunction with a Preventive Service, the problem oriented visit may be billed with an established patient Evaluation and Management code.

The problem oriented portion of the visit must be significant and separate identifiable. A 25 modifier is required on the problem oriented visit.

In a scenario where an E/M code is billed in addition to the preventive service, you should associate Z00.01 with the preventive care code, and the medical diagnosis(es) addressed at the visit with the E/M code. If you utilize Z00.00 in this situation, you more than likely will receive a denial for the E/M code.

A:  Transmittal 1719 , dated August 31, 2001, (that hasn’t been superseded since), reads, “All claims for pre-operative medical examination and pre-operative diagnostic tests (i.e., pre-operative medical evaluations) must be accompanied by the appropriate ICD-10 code for pre-operative examination. Additional appropriate ICD-10 codes for the condition(s) that prompted surgery and for conditions that prompted the pre-operative medical evaluation (if any) should also be documented on the claim. Other diagnoses and conditions affecting the patient may also be documented on the claim, if appropriate.”

So you should list the screening diagnoses first, and then any diagnosis(es) for condition(s) found. In this scenario, you should bill  Z13.6  (Encounter for screening for cardiovascular disorders), and the second diagnosis would be
 I45.10  (Unspecified right bundle-branch block).