Coding and Documentation

Answers to Your Questions


Fam Pract Manag. 1999 Jan;6(1):16.

Coding fractional units of service


How should we code an injection of 17 mL of lidocaine hydrochloride? The most appropriate code I can find, J2000, specifies 50 mL.


If your billing system accommodates fractional units of service, you should code J2000 with .34 units of service. If not, you may want to code J2000 with modifier -52, which indicates “Reduced Services.” To be certain, contact the third-party payer.

Documenting medical necessity for tests


If a test I order is negative, does that automatically qualify it as a screening test?


No. Medical necessity will be determined based on the rationale for ordering the test, as indicated in your chart documentation.

Coding tests for therapeutic levels


How do we code for obtaining therapeutic drug levels, and are there guidelines that say how often we can perform such tests on Medicare patients?


Use the appropriate CPT code for the test and ICD-9 code for the condition you are treating. There are no national guidelines regarding how often you can perform certain lab tests, although HCFA is engaged in a national rule-making process that may affect this. Without a national policy, Medicare carriers have discretion to establish their own policies, so check with the medical director of your carrier to determine whether a policy is in effect.

Substitutions for bulleted exam elements


Is it permissible to make substitutions for bulleted items in the exam documentation guidelines?



Same-day annual exam and flex sig


How should I code an annual exam and flexible sigmoidoscopy provided on the same day?


Use the appropriate office visit code for the exam and 45330 for the flexible sigmoidoscopy.

Consultation vs. ED visit


If I see a patient in the emergency department (ED) at the request of an emergency physician, should I use an outpatient consultation code or an ED visit code?


When an emergency physician documents a request for your consultation but retains care of the patient, you probably should use the appropriate consultation code (99241–99245). Once the emergency physician transfers the responsibility for treatment to you, if you then treat the patient in the ED and send the patient home rather than admitting him or her, you should use the appropriate ED visit code (99281–99285).

Coding telephone calls


How do I code a phone call with a patient?


There are three codes for this purpose: 99371-99373. Note, however, that third-party payers generally don't reimburse for phone calls.

Coding a sports physical


What code should I use to report a sports physical?


If it involves a comprehensive history and exam, use the age-appropriate preventive services code. Otherwise, use the appropriate office visit code.

Coding a test's professional component


How do we code a diagnostic test, such as spirometry (94010), for which the physician provided only the professional component of the service (i.e., the interpretation and report)?


If there is no separate CPT code solely for the professional component of a service, you can submit the code for the service with a -26 modifier, which indicates “Professional Component.”

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.

Leigh Ann Henry is a freelance writer in Kansas City, Mo.


Copyright © 1999 by the American Academy of Family Physicians.
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