Friday, January 9, 2015

2015 Happy New Year - A quick Update and Tips for better Clinical Documentation

First of all, I really want to thank you all for your continued support of my blog site, and what I strive to do each an every day. I have determined that this year (2015) will be the 'YEAR OF HAPPY' . With that, I have good news to share, over the last couple of months, I had been deep in studying for the CDIP exam. AND I PASSED!!! (Clinical Documentation Improvement Practitioner credential from AHIMA)

I fell that this new credential adds more "authority" behind what I can bring to coding practice, coding excellence, Physician collaboration and overall compliance medical documentation of necessity and good patient care. That being said, It is important to not only continue our work toward learning and implementing our ICD-10 diagnosis upgrade, we need to focus on the documentation needs that go hand in hand with ICD-10 conversion to make this the BEST Non-event since Y2K.

With that - Here is a copy of the article that I wrote for HCPro's and hope this brings you new education and information for a continued and successful 2015.

Tips for better Clinical Documentation: Preparing for ICD-10
As the clock is ticking back down again for the implementation of ICD-10cm there has been a lot of "push-back" from providers in regard to their willingness to really "jump on board" the ICD-10 train. It has the feel that they are overloaded and overwhelmed the moment you mention education for ICD-10cm. It is in that spirit, that if we can't get the education to the student in traditional methods, then maybe we can "disguise" in the form of improving the clinical documentation now.

As we begin the transition of this next year, here are a few areas of concern that we can work on now, to make it better prior to ICD-10 implementation.

Good documentation when reporting an annual wellness exam:

Medicare and many ancillary insurance providers will pay for an annual wellness exam both male and female patients. The wellness CPT codes are billed as age-appropriate codes, and are designated as "new" or "established". The criteria should be clearly noted within the examination of the patient. "New" patients are those that have not been seen by the same provider/practice within a 3 year time-frame. Established patients are those that have been seen by the same provider/practice within a 3 year time frame. As we transition to ICD-10 not only do we need to know if a patient is new or established, we also need clear documentation if the examination was for a general medical examination WITH or WITHOUT abnormal findings now will be required information for a coder to choose the most appropriate ICD-10 diagnosis.

The clinical documentation for the Annual wellness visits for Medicare and ancillary 3rd party payers needs to include
• Medical and Family History
• List of current medical providers
• Height, Weight, Blood Pressure, Body Mass Index,
• A simple vision test
• Risk screening for depression and personal safety
• Detection of Cognitive impairment
• Review of Age appropriate risk factors
• Review of functional ability
• Establish a written screening schedule (5-10 yrs out -- for screening such as mammogram, colonoscopy, etc..)
• Provider appropriate referrals for health education and/or preventive counseling services

Medicare has stated that the codes of 99387 and code 99397 (pt over the age of 65) will continue to be a non-covered service by Medicare, and will be adjudicated back to the patient as their responsibility to pay. As a coder, pay careful attention to the codes you are billing based upon patient age, and insurance carrier. If in doubt be sure to get an ABN signed.

CPT Wellness Codes: (Age Appropriate, New/Established)
99381 – 99387 New patientt
99391 – 99397 Established patient

Medicare Only – HCPCS Codes
G0438 – Annual Wellness Visit, Initial (applicable only during patient's first year with Medicare)
G0439 – Annual Wellness Visit, Subsequent (applicable after patients' first year with Medicare)

ICD-9 DX's:
V70.0 Routine general medical examination at health care facility

ICD-10 DX's Adults (age 18 and up)
Z00.00 Encounter for general adult medical examination without abnormal findings
Z00.01 Encounter for general adult medical examination with abnormal findings
Use additional code to identify abnormal findings
ICD-10 DX's Newborn (0 – 28 days old)
Z00.110 Newborn Health examination
Health check for newborn under 8 days old
Z00111 Health check for newborn 8 to 28 days old
(eg newborn weight check)

ICD-10 DX's Child (age over 28 days to 18 yrs)

Z00.121 Health check for child over 28 days old with abnormal findings
Use additional code to identify abnormal findings
Z00.159 Health check for child over 28 days old without abnormal findings.

In regard to “Well Child” exams, immunization(s) can be a large portion of the encounter, in addition to risk factor reduction an age-appropriate physical exam and growth and educational milestones. When coding and billing, the CPT wellness codes for newborn, pediatric and adolescent patients, as well as a code for the injection of the immunization serum, and the serum itself are used. The diagnosis codes in ICD-9 are also very specific for which serum correlates to a specific ICD-9 code. In ICD-10 however, the “serum” diagnosis has been much more descriptive. Yet now theICD-10cm code,

• Z23 - Encounter for immunization

Z23 can be used and it truly simplifies the billing and coding process. However, ICD-10 does give additional information that the coder/biller is to code first any routine childhood examination, (eg the wellness code) and that procedure codes are required to identify the types of immunizations given. The clinical exam documentation of these wellness exams for children can include a variety of topics based upon a provider’s medical preferences. The CDC has a large volume of information on these milestones, and can help clarify to coders and billers what is included in a particular age appropriate milestone guideline. The CDC also has a schedule of age appropriate vaccines and when they are to be given on the website too.

Annual Well Woman Exam Codes

Medicare allows billing for an annual "well woman" exam to be billed with the HCPCS codes of G0101 and Q0091. However, there are specific guidelines from CMS as to what clinical documentation must be reflected in the medical record. Some 3rd party insurance payers will also accept these HCPCS codes when billing a well woman exam, in lieu of billing the traditional CPT wellness exam codes of 99381 – 99387. In good clinical practice

G0101 – Cervical or Vaginal Cancer screening; pelvic and clinical breast examination
Q0091 –Screening Papanicolaou (PAP) smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory.

 Encounter for general GYN exam
• Did the provider perform a breast and pelvic exam? If so did they document 7 out of 11 of these elements?
 Inspection and palpation of breasts for masses or lumps, tenderness, symmetry, or nipple discharge;
 Digital rectal examination including sphincter tone, presence of hemorrhoids, and rectal masses;
 External genitalia (for example, general appearance, hair distribution, or lesions);
 Urethral meatus (for example, size, location, lesions, or prolapse);
 Urethra (for example, masses, tenderness, or scarring);
 Bladder (for example, fullness, masses, or tenderness);
 Vagina (for example, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, or rectocele);
 Cervix (for example, general appearance, lesions, or discharge);
 Uterus ‘status (for example, size, contour, position, mobility, tenderness, consistency, descent, or support); If your patient has had a hysterectomy, also denote if uterus is absent, and also if patient has tubes/ovaries status post hysterectomy
 Adnexa/parametria (for example, masses, tenderness, organomegaly, or nodularity);
 Anus and perineum

• Did the provider do a cervical or Vaginal PAP smear? If so, you can bill a Q0091 in addition to the G0101.

• V72.31Routine gynecological examination

• 2015 ICD-10-CM Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings
• 2015 ICD-10-CM Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings

In ICD-10, Physicians/providers must document whether the exam is with or without abnormal findings, as this affects code assignment and in some cases reimbursement . If abnormal findings are made, document what you found. (eg, red, inflamed, bleeding, patchy) and add the additional appropriate ICD-10 codes.

The old adage “if it wasn’t documented it wasn’t done still stands true, but to make our documentation we need to update this adage to: “If it wasn’t “clearly documented” – what WAS done?, It only takes a few steps to enhance what is in place now, and be prepared for the ICD-10 diagnosis documentation requirement. :

Utilize these quick steps to make it better for everyone:

• If documentation is unclear or illegible, Query the provider and have it clarified, and/or include tip on how to make the information more legible, and or straightforward .

• If the documentation is incomplete, or falls into a “not otherwise specified” code, ask the provider to clarify and/or addendum the information in the medical record, prior to billing the claim. At that time, also request that the provider include the enhanced information on each patient with a similar diagnosis there on out.

• If you are unsure, query and correct any and all documentation prior to coding and billing claims. It is always better to do it right the first time.

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding. She can be reached via e-mail at or you can also find current coding information on her blog site:

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