![]() If you utilize Z00.00 in this situation, you more than likely will receive a denial for the E/M code.Ī: Transmittal 1719, dated August 31, 2001, (that hasn’t been superseded since), reads, “All claims for pre-operative medical examination and pre-operative diagnostic tests (i.e., pre-operative medical evaluations) must be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. 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. A 25 modifier is required on the problem oriented visit. The problem oriented portion of the visit must be significant and separate identifiable. 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.Modifier 25 should be added to the Office/Outpatient code. 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.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. ![]() What diagnoses do I use when I bill the EKG? The EKG showed that the patient has a right bundle branch block. Q: We have a patient who needed a pre-op clearance prior to a major surgery, and an EKG was ordered. You should also bill the chronic stable conditions (i.e., hypertension and diabetes) along with the Z00.00. 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?Ī: Z00.00 (Encounter for general adult medical examination without abnormal findings) would be appropriate since there are no new findings at the visit. A yearly exam was done and the chronic conditions were managed. Q: One of our patients came in for an annual checkup with diagnoses of hypertension and diabetes.
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