From the Research
For an annual wellness visit, you should use the ICD-10 code Z00.00 (Encounter for general adult medical examination without abnormal findings) or Z00.01 (Encounter for general adult medical examination with abnormal findings) as the primary diagnosis code, as recommended by recent studies 1. When it comes to patients with diabetes or other chronic conditions, it's essential to prioritize their overall health and well-being, focusing on morbidity, mortality, and quality of life as the primary outcomes.
- The wellness visit code should always be listed first, as it's the primary reason for the encounter, ensuring proper billing and accurately reflecting the nature of the visit.
- If diabetes or other chronic conditions are addressed during the wellness visit, you can list them as secondary diagnoses, using codes such as E11.9 for Type 2 diabetes mellitus without complications, as supported by studies 2, 3.
- Using chronic condition codes as the primary diagnosis for a wellness visit could be considered incorrect coding and may lead to claim denials or auditing issues, highlighting the importance of accurate coding practices 4, 5. Some key points to consider when conducting an annual wellness visit include:
- Documenting any preventive services provided, screenings performed, and counseling given during the wellness visit to support the use of these codes.
- Ensuring that the visit is focused on preventive care and health promotion, rather than solely on managing chronic conditions.
- Using a structured approach to the visit, such as the Alzheimer's Association Medicare Annual Wellness Visit Algorithm for Assessment of Cognition, to help identify potential cognitive impairments and other health issues 5.