CODING & DOCUMENTATION
Answers to Your Questions
Fam Pract Manag. 2005 Jan;12(1):21.
- Prolonged services: the codes vs. the modifier
- 99000 and in-office tests
- Pap smear specimen
- Splinter removal
- Dexamethasone and Xylocaine injections
- Casting and follow-up
- Coding hyperbaric oxygen therapy
Prolonged services: the codes vs. the modifier
The article “Coding for Depression Without Getting Depressed,” [FPM, March 2004, page 23] states that “you may want to use prolonged services codes (99354-99355) in addition to the basic E/M service if the face-to-face time spent with the patient is at least 30 minutes or more than the typical time associated with the E/M code.” Isn’t it also true that the physician must use the highest level E/M code for that particular patient’s status first (e.g., 99215 for an established patient)?
No. I believe you are confusing the prolonged services codes (which may be used with any level of service) with modifier -21, “Prolonged [E/M] services,” which may only be attached to the highest level code in a given family of E/M services. CPT makes it clear that the prolonged services codes may be used with more than just the highest level code in a given family when it specifically states that outpatient prolonged services code 99354 should be used in conjunction with codes 99201-99215, 99241-99245 and 99301-99350. On the other hand, the description of modifier -21 states that “when the face-to-face or floor/unit service(s) provided is prolonged or otherwise greater than that usually required for the highest level of [E/M] service within a given category, it may be identified by adding modifier -21 to the [E/M] number.”
Note that the above rules don’t apply when time is considered the key or controlling factor in your selection of the E/M service code. In such cases, the prolonged services code should only be used in addition to an E/M service code if the service has extended 30 minutes beyond the time assigned to the highest level of E/M code in the appropriate category. If the service is longer than the typical time for the highest level of E/M code in that category and less than 30 minutes beyond the time assigned to the highest level of E/M code, modifier -21 should be attached to the E/M code to indicate the extended service.
99000 and in-office tests
Is it appropriate to submit CPT code 99000, “Handling and/or conveyance of specimen for transfer from the physician’s office to a laboratory,” for in-office tests such as dipstick urinalysis, wet prep, stool guaiac, quick strep and urine pregnancy test?
It is not appropriate to submit 99000 for in-office tests. According to CPT, 99000 is intended to be used when the physician incurs costs for the handling and/or transportation of a specimen to the laboratory (e.g., via messenger service), and it may also be used to reflect the work involved in the preparation of a specimen prior to sending it to the laboratory (e.g., centrifuging a specimen, separating serum, labeling tubes, packing the specimens for transport, filling out lab forms and supplying necessary insurance information and other documentation). For in-office tests, you should submit only the appropriate code for the test itself (e.g., 82270 for stool guaiac). Note that Medicare and many other payers consider code 99000 to be a bundled service that is not separately payable.
Pap smear specimen
What code(s) should I submit for obtaining a Pap smear specimen?
There is no separate CPT code for obtaining a Pap smear specimen, because CPT considers this to be part of another service rendered at the same encounter (e.g., a screening Pap smear done in conjunction with a preventive medicine visit or a diagnostic Pap smear done at a problem-oriented visit). If the specimen is sent to an outside laboratory, CPT code 99000, “Handling and/or conveyance of specimen for transfer from the physician’s office to a laboratory,” can be submitted for handling the specimen but should not be used for the collection of the Pap smear as part of a physical exam. Note that payers’ reimbursement of this code is inconsistent.
For Medicare, you can submit Q0091, “Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory,” when obtaining a Pap smear specimen for screening purposes (like CPT, Medicare considers the collection of a diagnostic Pap smear to be included in the E/M code for the visit). For low-risk Medicare patients, you should also submit ICD-9 code V76.2, “Special screening for malignant neoplasms; cervix,” V76.47, “Special screening for malignant neoplasms; vagina,” or V76.49, “Special screening for malignant neoplasms; other sites.” For high-risk Medicare patients, you should also submit V15.89, “Other specified personal history presenting hazards to health; other.”
What CPT code should I submit for removing a splinter from a patient’s finger?
The answer depends on the depth of the splinter and how you removed it. Here are your options:
20520, “Removal of foreign body in muscle or tendon sheath; simple.”
20525, “Removal of a foreign body in muscle or tendon sheath; deep or complicated.”
10120, “Incision and removal of foreign body, subcutaneous tissues; simple.”
10121, “Incision and removal of foreign body, subcutaneous tissues; complicated.”
Note that if the splinter is superficial or otherwise does not require an incision to remove, you should simply submit the appropriate E/M service code. Keep in mind that the documentation in the medical record should support the code used. For example, if you use 10120 or 10121, make sure the record reflects that an incision occurred with the removal.
Dexamethasone and Xylocaine injections
How should we code an injection of 1 cc dexamethasone and 0.5 cc Xylocaine?
Depending on the form of dexamethasone given, you should submit J1094, “Injection, dexamethasone acetate, 1 mg,” or J1100, “Injection, dexamethasone sodium phosphate, 1 mg.” If, as it appears in this case, the Xylocaine is being given as local anesthesia associated with a procedure, it is not separately reportable since the CPT surgical package includes “local infiltration, metacarpal/metatarsal/digital block or topical anesthesia.” Otherwise, J2001, “Injection, lidocaine HCl for intravenous infusion, 10 mg,” can be used where appropriate. Note that these codes only represent the drugs in question; they do not include administration. A separate code for administration (e.g., 90782) may also be appropriate, depending on the circumstances in which the drugs were administered.
Casting and follow-up
I treated a patient in the emergency room for a leg fracture and applied a cast in the process. The patient followed up with me in the office a week later complaining of shoulder pain, and, because the original cast was damaged, I applied a replacement cast to the leg. What code(s) should I submit for the services provided during the office visit?
You should submit the appropriate casting code for the replacement cast you applied and the appropriate established patient office visit code with a primary diagnosis code that reflects the shoulder pain (e.g., 719.41, “Pain in joint; shoulder region”). You may also want to attach the following modifiers to the E/M code: -24, “Unrelated [E/M] service by the same physician during a postoperative period,” and -25, “Significant, separately identifiable [E/M] service by the same physician on the same day of the procedure or other service.” Modifier -24 indicates that the diagnosis and treatment of the shoulder pain is not part of the normal follow-up care for the fracture treatment, and modifier -25 indicates that the E/M service is significant and separately identifiable from the casting code.
Coding hyperbaric oxygen therapy
Is there a CPT code for hyperbaric oxygen therapy?
Yes. Code 99183 is for “physician attendance and supervision of hyperbaric oxygen therapy, per session.” Note that, according to the CPT manual, [E/M] services and/or procedures (e.g., wound debridement) provided in a hyperbaric oxygen treatment facility in conjunction with a hyperbaric oxygen therapy session should be reported separately.
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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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