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    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. 


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