Preventive care intends to help patients by identifying potential health problems. As reporting only meant for asymptomatic patients, which require comprehensive documentation. This article will focus on the coding guidelines of the ICD-10 codes from Chapter 21 to describe the preventive care services. Although the ICD-10 preventive codes are straightforward, yet encounter complications in the combination of CPT/HCPCS and ICD-10 codes.
Coding guidelines for Immunizations:
Every billed service for preventive visits describes the reason with a CPT or HCPCS code. Codes for any immunizations report under Z23 regardless of the number or type of vaccines. Therefore, instead of individual diagnosis codes, the reporting is under multiple childhood immunizations. The Z codes encounter for influenza are addressed under ICD-10. V04.81 for influenza immunization in ICD-9 whereas, V06.6 for pneumonia and influenza if taken on the same date. For simplification, ICD-10 recommends only Z23 irrespective of the type of vaccines or number documented. According to the Z23 code set, a well-child visit coinciding with immunizations, in that case, a code for routine health examination is reported first.
Coding guidelines for Well-Child Examinations:
Well-child examinations are similar to ICD-9 rules. Z code for health examination for a newborn under eight days old is Z00.110. Health examination for newborn eight to twenty-eight days old, report code Z00.111. Additionally, Z00.121 & Z00.129 code set for routine child health examination with and w/o abnormal findings. Every billed service requires code for any abnormalities, irrespective of additional reported service.
Coding guidelines for Adult Annual Examinations:
The reporting in the adult annual examinations is similar to the well-child exam, including any abnormalities findings. For example:
Z00.00 for general adult medical examination w/o abnormalities,
Z00.01 for adult annual examinations with abnormalities,
Z01.411 for gynecological examination (routine) (general) with bnormalities, Z01.419 for gynecological examination (routine) (general) without abnormalities
For gynecological examination, there are additional codes needed for a screening vaginal Pap smear is Z12.72. Screening for human papillomavirus is Z11.51, and if applicable, Z90.71 for the absence of uterus. For outside gynecological examination, Z12.4 for Pap smear for malignant neoplasm of the cervix. Otherwise, Z01.411 or Z01.419 as a part of the gynecological exam.
Coding guidelines for Vision or hearing Examinations:
Code set for eyes and vision examination also relies on the abnormal findings. For example:
Z01.00 for eyes and vision examination w/o abnormalities,
Z01.01 for eyes and vision examination with abnormal findings
Your code selection for a routine examination of the ears and hearing is dependent on any abnormal findings. ICD-10 codes are as follows:
Z01.10 for the examination of the ears and hearing w/o abnormalities,
Z01.110 for hearing screening when the patient failed a hearing test. For instance, a child suspects having hearing problems. Whereas after the diagnosis not result so. In that case, an appropriate diagnosis code would suffice,
Z01.118 for screening ears and hearing with other abnormalities
Coding guidelines for Preventive Screenings:
ICD-10 codes for preventive screenings are pretty straightforward. For instance:
Z13.6 code for cardiovascular disorders,
Z12.11 code for malignant neoplasm of colon,
Z13.89 code for other disorders like depression,
Z13.1 code for diabetes mellitus,
Z11.4 code for HIV (human immunodeficiency virus),
Z13.88 code for disorder due to exposure to lead or other contaminants,
Z13.220 code for lipoid disorders,
Z68.30-Z68.45 codes for IBT (obesity intensive behavioral therapy),
Z13.820 code for osteoporosis,
Z12.5 code for prostate cancer,
Z11.1 codes for respiratory tuberculosis,
Z11.3, Z72.89, Z11.59, and Z11.8 codes for sexually transmitted infection (STI)