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icd 10 coding for yearly exams

Cathy Posted Tue 29th of September, 2015 20:10:36 PM

The coding for yearly exams is with normal finding and abnormal findings. Does the the abnormal finding mean that the physician found something during this exam or does it includes a past history such as an abnormal pap smear.

Thank you

SuperCoder Answered Wed 30th of September, 2015 02:18:16 AM

Normal and abnormal findings totally depend on physician's exam. If a patient came with past history of abnormal pap smear, however, physician's exam is normal. Then bill it as normal without abnormal findings.

Cathy Posted Wed 07th of October, 2015 15:54:58 PM

If the patient comes in for a well woman exam and and the physician find that she has a UTI. Is that an abnormal finding. Can you also bill the well woman exam and then a 99212 with a 25 modifier like we did before. Or is the purpose of billing a well woman exam for normal finding or abnormal findings it to not to allow us to bill a 99212 for additional problems that the physician finds. Are we reimbursed more for an abnormal finding?
Thank you

SuperCoder Answered Fri 09th of October, 2015 09:41:51 AM

Well, yes, UTI during well exam visit counted as abnormal finding. If the well exam visit is fixed as preventive medicine service visit and you come across with abnormal findings (like-UTI) and patient take treatment for abnormal finding(s), then code both-preventive medicine service as well as office visit (99201-99215). On the other hand, if patient is coming for office visit for well exam and taking the treatment for abnormal findings then append well exam ICD code and abnormal finding ICD code also for the support of office visit code (99211-99215).
Hope it helps!

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