Take a look at these key factors in your physician’s documentation.
It’s a known fact that when ICD-9 becomes ICD-10 in 2013, you’ll not always have a simple crosswalk relationship between old codes and the new ones. Many a time, you will have more choices that may need tweaking the way you document services and a coder reports it.
Here’s a common routine child health check vision scenario that will help you discover what you will report post October 1, 2013.
Present way: When a patient comes in for a scheduled preventive wellness exam, you should attach V20.2 (Routine infant or child health check) to an annual visit code (99381-99385 for new patients, or 99391-99395 for established patients).
ICD-10 difference: This year, you will go for Z00.129 (Encounter for routine child health examination without abnormal findings) to reflect the physician’s visit. If the physician did face abnormal findings during the visit, you would instead use Z00.121 (Encounter for routine child health examination with abnormal findings).
Physician documentation: The main difference between Z00.129 and Z00.121 is whether the visit showed an abnormal finding during the examination of the patient. The pediatrician must document this. For example, the physician might examine the patient and note, “patient appears severely speech delayed, which leads to the decision to carry our further testing”.
‘Abnormal findings’ does not refer to a blood test, biopsy, or a test that went to pathology. Oftentimes, these key abnormal findings would support a separate E/M visit billed with a (Significant, separately identifiable by the same physician on the same day of the procedure or other service) during the time of a preventive medicine visit.
Tips for coders: Instead of relying on V20.2 as your catch-all annual visit diagnosis, you will need to examine your physician’s documentation. To put it in other words, you will be looking at the examination part of the visit and what the pediatrician notes as his findings.