Coding and Documentation

Answers to Your Questions


Fam Pract Manag. 1999 Sep;06(8):16.

Two physicians, one admission


Physician A sees a patient in his office and determines that the patient needs to be admitted to the hospital, so he sends the patient to the hospital, where Physician B does the same-day admission. Can both physicians be reimbursed for their respective services?


Yes. However, if one of the physicians had provided both the office visit and the hospital admission, he or she could only be reimbursed for the hospital admission.

Two physicians, one delivery


How should we bill a vaginal delivery involving both a family physician and an obstetrician?


When an obstetrician performs the delivery service only, he or she should bill one of the delivery-only codes, such as 59409. When the family physician assists, he or she can bill the same code with an -80 modifier (Assistant surgeon). For more information on coding for intrapartum care and other obstetrical services, see the Academy's discussion paper on this subject at

Coding a limited well-woman exam


If a patient wants a breast and pelvic exam only and preventive care related to hormone-replacement therapy or contraception, how should the service be coded? By my understanding, a preventive medicine code always includes a comprehensive physical exam. How can I code a limited encounter for a Medicare or privately insured patient?


Medicare considers the HCPCS code G0101, “Cervical or vaginal cancer screening; pelvic and clinical breast examination,” equivalent to CPT code 99202, so G0101 could be used for providing a limited exam for a Medicare patient. If your other payers recognize Level II HCPCS codes, you may be able to use G0101 for non- Medicare patients, too.

If a payer does not recognize HCPCS codes, the answer is less clear. A preventive medicine code such as 99395 still seems most appropriate even if the exam was not comprehensive. According to CPT, the comprehensive exam of the preventive medicine codes is not synonymous with the comprehensive exam that other E/M codes require. CPT also stipulates that “the extent and focus of the [preventive medicine] services will largely depend on the age of the patient,” so there is some anticipated variability in the extent of these services.

Re-established patient


A patient left our practice two years ago, we released his records, and now he has returned as an active patient. Should we code his first visit as a new or established patient visit?


CPT defines an established patient as “one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.” Since your patient's return comes less than three years after he left your practice, you should use an established patient visit code. This assumes, of course, that the patient received services from you or your colleagues during his last year with your practice. If not, you could now consider him a new patient.

Minor procedures without their own codes


How should I code the in-office removal of a subclavian catheter that was placed by another provider?


I could not find any specific code for this service. For minor office procedures that don't have their own codes, CPT typically advises physicians to code the appropriate-level office visit.

Vitamin B-12 injection


What's the J code for a Vitamin B-12 shot?


J3420, “Injection, vitamin B-12 cyanocobalamin, up to 1,000 mcg.”

X-ray code components


Do the CPT codes for plain X-rays (for example, 71010, “Radiologic examination, chest; single view, frontal) include the technical and professional components?


Yes. When these codes are billed without a modifier, they are generally understood to include both the professional and technical components. If the professional component needs to be reported separately, you should attach modifier -26, “professional component,” to the code to indicate that you are billing for this component only.

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.


Copyright © 1999 by the American Academy of Family Physicians.
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