Coding and Documentation

Answers to Your Questions


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Fam Pract Manag. 1999 Mar;6(3):18.

Coding treatment of “road rash”


What would be the appropriate code for treating a patient who has “road rash”?

Debridement of an abrasion such as “road rash” most likely would be coded as 11040 or 11041, depending on whether it's a partial-or full-thickness abrasion. Note that these codes would include application of any topical anesthetic before the debridement.

A diagnosis code for poor posture


Does ICD-9 list a diagnosis code for poor posture?

Not specifically. Your best bet is 781.9 (other symptoms involving nervous and musculoskeletal systems).

Destruction of multiple lesions


Code 17000 covers destruction of one benign or premalignant lesion, and 17003 covers destruction of benign or premalignant lesions, the “second through 14 lesions, each.” Does this mean that if I destroyed five such lesions I would bill 17000 once to cover the first lesion and 17003 four times to cover the remaining lesions?

Yes. The codes' descriptions may not be the most clear that CPT has to offer, but your interpretation is correct.

Coding for house calls


How should I code house calls?

Use codes 99341-99350 to report evaluation and management (E/M) services “provided in a private residence.” Like other E/M services, the proper level of service for a home visit depends on the levels of the history and examination as well as the complexity of the medical decision making that the visit involves. Note that there are separate home-visit codes for new patients (99341-99345) and established patients (99347-99350).

Services in an adult day-care center


What CPT code should I use for an E/M service provided to a patient in an adult day-care center?

The best choice probably would be one of the “office or other outpatient services” codes (99201-99215). People tend to think of these codes as officevisit codes only. However, according to CPT, you may use these codes to report E/M services provided “in an outpatient or other ambulatory facility.” An adult day-care center would seem to fit this description.

Coding inpatient care of an infant


Should I use the newborn-care codes to report treatment of a hospitalized infant?

No. According to CPT, the newborn-care codes (99431–99435) are for “normal newborn” care. For services provided to an infant in the hospital, use the E/M codes for initial (99221–99223) and subsequent (99231–99233) hospital care.

Observation care or a nursing facility admission?


Can I code hospital observation care (99219) and assessment of a nursing facility patient at the time of admission (99303) on the same date of service?

No. CPT indicates that when a patient is admitted to a nursing facility during the course of an encounter in another setting (e.g., hospital observation care) on the same date, you should submit only the code for the nursing facility admission. An exception to this rule is hospital discharge (99238-99239) or observation discharge (99217) services performed on the same date as a nursing facility admission. These services may be reported separately.

Getting paid for FMLA paperwork


Is there a code I can use to bill for completing paperwork related to the Family and Medical Leave Act?

Try code 99080, “Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form.”

Editor's note: While this department represents our best efforts to provide accurate information and useful advice, we can't guarantee that third-party payers will accept the coding and documentation recommended. For more detailed information, refer to the current CPT manual and the “Documentation Guidelines for Evaluation and Management Services.”


Kent Moore is the AAFP's manager for reimbursement issues and a contributing editor to Family Practice Management.

John Spicer is senior editor of Family Practice Management.


Copyright © 1999 by the American Academy of Family Physicians.
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