99215/physical exams

[bosox85]

I am brand new to coding.Please forgive me if this question is very basic. I was hired 8 months ago as an accounting clerk and have pretty much been thrown in the billing for the practice because of employee departures and no one else there knows anything about coding.When a practitioner performs an annual physical for a patient, can these be billed as cpt 99215? Can 99211-99215 ever have a Z00.00 as a first dx?

[PMRNC]

No way to answer this.
I'ts valid dx, valid service, but not enough info

[Michele]

Linda is right, not enough info to answer, however are you aware of the E&M codes for annual visits?  99381-99431  That might help.

[bosox85]

Thank you Linda and Michelle! I appreciate your time!
Can you tell me is it OK to leave a diagnosis off a claim? The practitioners where I work do their own charting (with many errors) Example: Patient come in for an OV. The E/M is 99215 with dx Z00.01, F90.0, I10. Practitioner left the Z code off the claim even though it is charted this way. It happens often and I have been instructed to never question the practitioners, so I’m hoping to get some insight into why so I can fully understand. Thank you 

[Michele]

Are you a (certified) coder?  Your original post says you were hired as an accounting clerk and thrown into the billing.   The reason I ask is because you said that it is charted with the Z00.01 but it's coded as a medical E&M so I'm wondering if the provider is leaving it off because the visit was for the medical reasons and really wasn't a routine check at all.  Some times patients schedule a "check up" but it's really a medical check up.  The routine dx is there, but not really appropriate for the visit.  Only the provider would be able to tell that, or a certified coder that is reviewing the notes. So I'm wondering what is making you concerned.  Maybe a little more info?

[PMRNC]

Are you billing from chart notes? I agree with Michele that if so and you were thrown into this job, I'll add that you have assumed a great responsibility and liability and it's even more risky w/out being certified coder.

Assuming as you say the dr charted the Z00.01, it should not be left off. Z00.01 is used if there are new findings/changes in chronic conditions that are treated that visit and would be used along with the appropriate codes for the findings of that visit listed secondary.