Fam Pract Manag. 2001 Mar;8(3):23.
- Initial observation care + initial hospital care
- Calculating prolonged services
- Preventive medicine codes
- Sebaceous cyst excision
Initial observation care + initial hospital care
If I admit a patient for “23-hour observation” and then it is necessary to convert that to a regular admission at the 24-hour mark, what code should I use?
CPT says, “When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service (e.g., hospital emergency department, observation status in a hospital …), all evaluation and management (E/M) services provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission.” This means that at the point you admit the patient to the hospital, all of your services provided in conjunction with that admission on that date are coded using one of the initial hospital care codes, 99221–99223. Assuming the initial observation care you provided spanned two dates (i.e., you admitted the patient to the hospital the day after you admitted him or her to observation), you would code your services on the first day using one of the initial observation care codes, 99218–99220, and then use one of the initial hospital care codes to code the admission on the second day.
Calculating prolonged services
I recently spent 70 minutes providing a level-III established patient office visit. Which prolonged services code should I use?
99354. This is determined by subtracting the time that CPT indicates is typically associated with the level of office visit you provided from the time you actually spent in face-to-face contact with the patient. The CPT manual says a 99213 typically involves 15 minutes of face-to-face time. Subtracting 15 from 70 leaves 55 minutes. Prolonged services code 99354 accounts for the first hour of direct patient contact “beyond the usual service,” according to CPT. It may be used to report prolonged service of 30 minutes to one hour and should be submitted with the office visit code. If the prolonged service exceeded one hour, you could also submit 99355.
Preventive medicine codes
What is required for documenting a preventive medicine evaluation? Is a review of systems required?
According to CPT, the “extent and focus of the services will largely depend on the age of the patient.” As such, the expected documentation will vary considerably between, for example, a preventive medicine evaluation of an infant and a 65-year-old.
The preventive medicine codes (i.e., 99381–99397) include a comprehensive history, a comprehensive examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate laboratory/diagnostic procedures, according to CPT. Here’s what that means, according to the August 1997 issue of CPT Assistant, a newsletter published by the AMA, which owns and maintains CPT: Because the comprehensive history obtained as part of the preventive medicine E/M service is not problem-oriented, it does not involve either a chief complaint or history of present illness. It does, however, include a comprehensive review of systems and a comprehensive or interval past, family and social history, as well as a comprehensive assessment/history of pertinent risk factors. I learned from the same source that the comprehensive examination of the preventive medicine codes 99381–99397 is not synonymous with the comprehensive examination required in E/M codes 99201–99350. Thus, it seems the comprehensive examination performed as part of the preventive medicine E/M service should be a multisystem exam, the extent of which is based on the age of the patient and identified risk factors.
Sebaceous cyst excision
What CPT code should we use for excision of a sebaceous cyst?
A code for excision of a benign lesion (e.g., 11400), specific to location and size of the cyst, would probably be most appropriate.
Editor’s note: While this department represents our best efforts to provide accurate information and useful advice, we cannot 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.”
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Copyright © 2001 by the American Academy of Family Physicians.
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