The Coding Cove

​​​​​​​Kathy Barbagallo, our seasoned CPC coding educator at Lighthouse, meets with providers and coders on a regular basis. The Coding Cove is dedicated to sharing some of the frequently asked questions and answers to dilemmas that frequently plague providers....

Q: What diagnosis code should I use for the Medicare Initial Preventive Physical Examination (IPPE) an Medicare Annual Wellness Visit (AWV)? Is Z00.00 Encounter for general Adult medical exam sufficient?

A: CMS does not require a specific Diagnosis for this service. This is a great opportunity to compile the conditions the patients has, and document some of your MACRA/MIPS qualifiers.

Q: When the physician does a preventive physical, I am not sure when to use Z00.01-Encounter general adult medical examination with abnormal findings?

A: You would use this code when a new condition is found during the physical, not established conditions. Example: a patient currently being treated for hypertension, and the provider detects atrial fibrillation during the PE, you would code Z00.01 & I48.91 (A.Fib unspecified). When the patient returns after testing and it is determined what type of A-fib the patient has the code would then be changed to the more specific code.

Q: I already coded morbid obesity E66.01, why do I have to code the BMI?

A: E66.01 is morbid obesity due to Excess calories, it does not tell us how obese the patient is, and the BMI would give that information. Coding guidelines require that you assign the BMI code, if known.