ICD-10 CM strictly limits same day preventative visit and sick visit for same patient
ICD-10-CM strictly limits the circumstances under which a provider may report a same day preventative visit and sick visit for the same patient. Diagnosis code descriptions don?t allow split billing for sick patients at your office for a preventive exam. As per ICD-10-CM guidelines, the visit no longer qualifies as a preventive encounter, if the patient is symptomatic on arrival for a preventive visit. A sick visit may be billed, but the preventive visit should be rescheduled.
Codes describing preventive encounters are found in categories Z00Encounter 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:
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
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