Fam Pract Manag. 2003 Mar;10(3):23-24.
- Type-2 diabetes & insulin
- ECG & E/M
- Removal of skin lesions
- Retirement community visit
- Hospital observation to inpatient status
- Coding a tick bite
- Ring removal
- Sunday home visits
- Confirmatory consultation codes
Type-2 diabetes & insulin
When a patient with type-2 diabetes starts needing insulin, should we still submit type-2 diabetes ICD-9 codes for that patient, or should we submit type-1 diabetes codes since the patient is now insulin dependent?
You should keep using the type-2 codes for patients with type-2 diabetes and the type-1 codes for patients with type-1 diabetes regardless of insulin use. In your case, you should submit 250.x0 or 250.x2 (where x would be replaced by a digit indicating manifestations of the diabetes) to indicate that the patient has type-2 diabetes even though he or she may be on insulin. This reflects the fact that even though insulin is prescribed for a patient with diabetes, the type of diabetes has not changed.
ECG & E/M
After performing a treadmill stress ECG in my office, I spend about 15 to 20 minutes going over the test results and counseling the patient. How should I code this encounter – strictly as an office procedure, or as an office procedure and an office visit using modifier -25?
You should code for the stress ECG and the evaluation and management (E/M) service. The stress ECG code in this case would be 93015, “Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report,” since you and your office provided both the professional and technical components of the service. Also, attach modifier -25 to the E/M service, as you suggested, and the appropriate diagnosis code to indicate the reason for the test. Since you are discussing the test results and counseling the patient, the level of E/M service would likely be selected based on time rather than the key components of history, exam and medical decision making. Therefore, be sure to document the amount of time spent with the patient, indicate that more than 50 percent of the time was spent in counseling and coordination of care and summarize the discussion.
Removal of skin lesions
When coding the removal of multiple skin lesions, should I sum the sizes of the lesions to identify the correct CPT code?
No. The principle of summing lengths applies only to the skin repair codes (12001–13153) not the excision of skin lesion codes (11400–1446 and 11600–11646). You should separately measure and report each skin lesion (including associated margin) that you excise.
Retirement community visit
When I visit a patient who lives in a retirement community (i.e., the patient is renting an apartment and not receiving assisted living services), should I code the visit as a domiciliary (assisted living) visit rather than a home visit?
No. According to CPT, the home visit codes (99341–99350) are used to report E/M services provided in “a private residence.” The domiciliary visit codes (99321–99333) are used to report E/M services “in a facility which provides room, board and other personal assistance services, generally on a long-term basis.” A visit to a patient living independently in an apartment in a retirement community would be considered a home visit, since the patient’s apartment represents a “private residence” and the patient is not receiving “board and other personal assistance services” associated with domiciliary care or assisted living. Since some retirement communities provide both assisted living and independent living arrangements, it is important to distinguish in which part of the community the patient lives.
Hospital observation to inpatient status
Our hospital is encouraging us to use the hospital observation codes (99218–99220) for patients who may not be in the hospital for more than 23 hours. What CPT code should we submit for patients we fully admit on day two? Since they are technically outpatients on day one, should day two be coded as initial hospital care (99221–99223), or should it be coded as subsequent hospital care (99231–99233)?
According to CPT, when a patient is admitted to the hospital on a date subsequent to the date of observation status, the hospital admission should be reported using the appropriate initial hospital care code. Thus, in your example, if day one is being appropriately coded as initial observation care and the patient is formally admitted as an inpatient on day two, day two should be coded using the appropriate initial hospital care code. Be sure that your documentation supports the level of service billed and that the level of service reflects the work done on the date of the initial hospital care. Since much of the work regarding the initial hospital care will have been done for the observation admission the day before, some payers may not consider it medically necessary to do another comprehensive history and physical, for example.
Coding a tick bite
A patient presented with a tick bite, so we did a Lyme titer on the patient and sent the tick to our lab for testing. Since we didn’t know yet whether the patient was infected, we submitted the diagnosis code E906.4, “Bite of nonvenomous arthropod,” instead of 088.81, “Lyme disease.” However, the insurance company denied the lab charges because of incorrect coding. What did we do wrong?
It sounds as if you used E906.4 by itself as a primary diagnosis; if so, that may explain the denial by the insurer. E codes are intended as secondary diagnoses to classify environmental events, circumstances and other conditions as the cause of an injury, poisoning or other adverse effect. Try submitting V01.8, “Contact with or exposure to communicable diseases; other communicable diseases,” or V02.9, “Carrier or suspected carrier of infectious diseases; other specified infectious organism,” as a primary diagnosis for the lab work with E906.4 as a secondary diagnosis. Or, for the secondary diagnosis, use a code from the superficial injury section (910–919) that is specific to the anatomical site of the bite and then add a 4 as the fourth digit to represent “Insect bite, nonvenomous, without mention of infection.”
I work in an urgent care center and occasionally see a patient who needs a ring removed either because of a finger injury that causes enough swelling to place the vasculature at risk or because he or she realizes the ring is simply stuck. What CPT code should I submit for this?
There is no CPT code for the types of ring removal you describe. In those cases, the procedure would be included in the E/M service that you otherwise provide to the patient. However, if a ring has to be excised from the skin, you could submit a code for foreign body removal, such as 10121, “Incision and removal of foreign body, subcutaneous tissues; complicated.” And if you perform a significant, separately identifiable E/M service in addition to this type of ring excision, you should also submit the appropriate E/M code with a -25 modifier.
Sunday home visits
What code should I submit for a Sunday home visit?
Use the appropriate home visit code (99341–99350) and 99054, “Services requested on Sundays and holidays in addition to basic service.” Be aware that Medicare and many other payers bundle or otherwise do not reimburse separately for 99054, so you may want to review your health plan contracts regarding the status of this code before you use it.
Confirmatory consultation codes
What code should I submit when a patient who is scheduled for surgery and has already received a preoperative history and physical from his or her surgeon shows up at my office on his or her own initiative to get my opinion “just to be safe”?
Consider using one of the confirmatory consultation codes (99271–99275). CPT indicates that these codes are appropriate for consultations initiated by patients seeking second opinions. You may provide confirmatory consultations in any setting. If you do not believe that the encounter fits the definition of a confirmatory consultation, use another appropriate E/M code.
Is there a code for the drug Cefobid?
Yes, there is an HCPCS code, S0021, “Injection, ceftoperazone sodium, 1 gram,” that you can use for Cefobid. However, S codes are temporary national codes not used by Medicare, so you might try submitting J3490, “Unclassified drugs,” for Cefobid administered to a Medicare patient.
Kent Moore is the AAFP’s manager for health care financing and delivery systems and is a contributing editor to Family Practice Management. These questions and answers were reviewed by members of the FPM Coding & Documentation Review Panel, which includes: Robert H. Bosl, MD, FAAFP; Marie Felger, CPC; Thomas A. Felger, MD, DABFP, CMCM; David Filipi, MD, MBA, and the Coding and Compliance Department of Physicians Clinic; Lynn Handy, CPC, LPN; Emily Hill, PA-C; Joy Newby, LPN, CPC; P. Lynn Sallings, CPC; and Susan Welsh, CPC.
Conflicts of interest: none reported.
Editor’s note: While this department attempts to provide accurate information and useful advice, third-party payers may not accept the coding and documentation recommended. 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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Copyright © 2003 by the American Academy of Family Physicians.
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