Fam Pract Manag. 2001 Oct;8(9):24.
Coding a cold
If an otherwise healthy, established patient presents with a cold, what level of visit should be coded? Technically, we could document enough history and physical to code for any level of visit.
Assuming you provided medically necessary levels of history, physical exam and medical decision making, you should submit the E/M code that corresponds to the level of service you provided and documented. The clinical examples in Appendix D of the CPT manual may help you determine what level of service would be appropriate for the type of problem you describe. For instance, examples of a 99212 visit include “Office visit, established patient, 6–year-old with sore throat and headache,” and “Office visit, sore throat, fever and fatigue in a 19–year-old college student, established patient.” As you noted, you could technically document enough history and physical to code for any level of visit, but that doesn’t make it medically necessary. For example, coding a level-V visit in your scenario is likely to invite charges of fraud and abuse.
B–12 with or without E/M
In the October 1999 issue [page 16], you recommended submitting 99211 for a B–12 injection. However, in the September 2000 issue [page 22], you stated that it is not appropriate to submit 99211 and instead recommended using an administration code in conjunction with a J code for the B–12 injection itself. Which is the appropriate way to code for an established patient who receives a B–12 injection?
The answer depends on whether there is an E/M component to the visit (i.e., a review of the patient’s history, examination of the patient or some medical decision making). If there is no E/M component, as was the case in the second article you referred to, an administration code should be submitted in conjunction with a J code for the B–12 injection itself (e.g., 90782 with J3420). If an E/M component is provided in addition to the administration of the B–12 injection, an E/M code such as 99211 may also be submitted with modifier –25 appended.
What is the proper code to submit when a newborn infant is seen in the office for the first time for a two-week, well-child check? If I saw the infant in the hospital, should the visit be coded as a well-child check of an established patient? What if one of my partners saw and discharged the infant from the hospital? What if a doctor from another practice who was covering for me or my practice saw the infant in the hospital?
When a newborn infant is seen in the office for a two-week, well-child check, you should submit a preventive medicine services code (99381 for a new patient or 99391 for an established patient). A new patient is one who has not received any professional services (defined in CPT as face-to-face services rendered by a physician and reported by a specific CPT code(s)) within the past three years from the physician or another physician of the same specialty who belongs to the same group practice. Therefore, if you or one of your family-physician partners saw the infant as a newborn in the hospital, you should submit 99391 for the well-child visit since the child is an established patient when he or she presents at the office. If a doctor from another practice saw the infant in the hospital, you should submit 99381 for the well-child visit since the child is a new patient to you and your group.
CPT for DOT
In the April 2000 issue [page 16], you recommended submitting ICD–9 codes V70.3 or V70.5 for a Department of Transportation (DOT) physical. What CPT code should be submitted: a preventive medicine services code or 99214/99215?
Both of the diagnosis codes referenced in the April 2000 issue fall under the heading of general medical examination given to a person without reported diagnosis. In such a case, I would recommend using one of the preventive medicine services codes (e.g., 99395) rather than a problem-oriented code (e.g., 99214 or 99215).
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. Because CPT and ICD-9 codes change annually, you should refer to the current CPT and ICD–9 manuals and the “Documentation Guidelines for Evaluation and Management Services” for the most detailed and up-to-date information.
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Send questions and comments to firstname.lastname@example.org, or add your comments below. While this department attempts to provide accurate information, some payers may not accept the advice given. Refer to the current CPT and ICD-10 coding manuals and payer policies.
Copyright © 2001 by the American Academy of Family Physicians.
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