Diagnosis code descriptions don’t allow split billing for sick patients at your office for a preventive exam.
ICD-10-CM strictly limits the circumstances under which a provider may report a same-day preventive visit and sick visit for the same patient. If the patient is symptomatic on arrival for a preventive visit, per ICD-10-CM guidelines, the visit no longer qualifies as a preventive encounter. A sick visit may be billed, but the preventive visit should be rescheduled.
ICD-10 Changes the Rules for Same-day Visits
Billing a sick visit with a wellness visit (sometimes called “split billing”) has been common practice. I contend that the adoption of ICD-10-CM last October has changed the rules, however, making split billing rarely appropriate. The reason lies in the descriptors for codes used to report preventive encounters.
Codes describing preventive encounters are found in categories Z00 Encounter for general examination without complaint, suspected or reported diagnosis and Z01 Encounter for other special examination without complaint, suspected or reported diagnosis. The codes necessarily include the category designation within their full descriptors. For example:
Z00.0- Encounter for general examination without complaint, suspected or reported diagnosis; Encounter for general adult medical examination; Encounter for adult periodic examination (annual) (physical) and any associated laboratory and radiologic examinations
Z00.1- Encounter for general examination without complaint, suspected or reported diagnosis; Encounter for newborn, infant and child health examinations
Z01.4- Encounter for other special examination without complaint, suspected or reported diagnosis; Encounter for gynecological examination
If the category descriptor does not apply, neither can the individual code in that category. By properly including the category designation into the descriptors, Z00.0-, Z00.1-, and Z01.4- are not appropriate if the patient has a current complaint, or a suspected or reported diagnosis. In other words, you cannot report a wellness encounter if the patient is sick.
Excludes Notes Strengthen the Rule
To reinforce this guideline, ICD-10-CM specifies an Excludes1 note to prevent reporting Z00.0- or Z01 in addition to signs and symptoms:
Type 1 Excludes:
encounter for examination of sign or symptom – code to sign or symptom
Type 1 Excludes:
encounter for laboratory, radiologic and imaging examinations for sign(s) and symptom(s) ̶ code to the sign(s) or symptom(s)
Note: The pediatric well visit codes do not have an Excludes1 note for signs and symptoms, but do carry the category description for each selection, “Encounter for general examination without complaint, suspected or reported diagnosis.”
ICD-10-CM defines an Excludes1:
A type 1 Excludes note is a pure excludes note. It means “NOT CODED HERE!” An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.
The Excludes1 notation means you may not list the affected Z00/Z01 codes with signs or symptoms codes in field 21 of the claim form, even if you link the diagnoses to different line items in field 24 of the form. The payer may accept the claim, but that doesn’t mean it’s coded correctly. A payer is not allowed to override the Excludes1 edits; only the World Health Organization (WHO), which maintains the ICD-10 code set, has that authority.
WHO has investigated complaints regarding some Excludes1 edits, and they published interim advice in October 2015 through the Centers for Disease Control and Prevention (CDC):
Updated October 26, 2015 (Original posting October 19, 2015) There are circumstances that have been identified where some conditions included in Excludes1 notes should be allowed to both be coded, and thus might be more appropriate for an Excludes2 note. However, due to the partial code freeze, no changes to Excludes notes or revisions to the official coding guidelines can be made until October 1, 2016. This new guidance concerning Excludes1 notes is intended to allow conditions to be reported together when appropriate even though they may currently be subject to an Excludes1 note. This coding advice has been approved by the four Cooperating Parties—the American Health Information Management Association (AHIMA), the American Hospital Association (AHA), the Centers for Medicare and Medicaid Services (CMS), and the National Center for Health Statistics (NCHS). This advice will also be published in the 4th Quarter 2015 issue of Coding Clinic for ICD-10-CM and ICD-10-PCS.
We have received several questions regarding the interpretation of Excludes1 notes in ICD-10-CM when the conditions are unrelated to one another. How should this be handled?
If the two conditions are not related to one another, it is permissible to report both codes despite the presence of an Excludes1 note. For example, the Excludes1 note at code range R40-R46, states that symptoms and signs constituting part of a pattern of mental disorder (F01-F99) cannot be assigned with the R40-R46 codes. However, if dizziness (R42) is not a component of the mental health condition (e.g., dizziness is unrelated to bipolar disorder), then separate codes may be assigned for both dizziness and the mental health condition. In another example, code range I60-I69 (Cerebrovascular Diseases) has an Excludes1 note for traumatic intracranial hemorrhage (S06.-). Codes in I60-I69 should not be used for a diagnosis of traumatic intracranial hemorrhage. However, if the patient has both a current traumatic intracranial hemorrhage and sequela from a previous stroke, then it would be appropriate to assign both a code from S06- and I69-.
The statement, “If the two conditions are not related to one another …” does not allow reporting of same-day well and sick encounters. Although you can have a patient who is both bipolar and experiencing (unrelated) dizziness, a patient cannot be both well and sick at the same time.
CPT® Guidelines Allow Some Exceptions
CPT® guidelines do allow for same-day sick and preventive visits:
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 problem oriented E/M service, then the appropriate Office/Outpatient code 99201-99215 should also be reported. Modifier 25 should be added to the Office/Outpatient code to indicate that a significant, separately identifiable evaluation and management service was provided on the same day as the preventive medicine service. The appropriate preventive medicine service is additionally reported.
Notice, however, that this instruction does not address the patient who presents for a well visit with symptomatic concerns; rather, it narrowly addresses a visit with abnormal findings or a pre-existing condition that requires additional workup. In these cases, you may report an office visit with the preventive visit, as long as there is documentation of an abnormal finding in the notes (a presenting symptom is not an abnormal finding). You must be sure to append modifier 25 to the office visit.
Look to Patient Scenarios for Clarity
Example 1: A patient is scheduled for a well visit. He arrives and is asymptomatic with no specific complaint, but during the course of the well visit a problem is discovered. Assuming documentation is complete, code for the well visit with abnormal findings. Also code an E/M service (if it was significant) to address the problem, and append modifier 25. Code the signs and symptoms, unless a definitive diagnosis is documented.
Example 2: A patient scheduled for a well visit is symptomatic when he arrives. For dates of service on or after October 1, 2016, you may not code a well visit, per ICD-10-CM. You must report a sick visit, and report the signs and symptoms, or (if confirmed) a definitive diagnosis.