Coding and Documentation

Answers to Your Questions


Fam Pract Manag. 1999 Oct;6(9):16.

Examples of 99211


Can 99211 be used in the following situations, none of which involve physician contact with the patient? 1. An established patient with pernicious anemia receives her regular B-12 shot, given by the nurse. 2. An established patient comes in for a blood-pressure check. 3. An allergy patient receives a desensitization injection, and a nurse rechecks the sites.


Coding 99211 would be appropriate in all three circumstances. For an extensive list that includes additional examples of services that meet the requirements for coding 99211, see Appendix D of the CPT manual.

Administration of BCG vaccine


What code should I use for administration of 90585, “Bacillus Calmette-Guerin vaccine (BCG) for tuberculosis, live, for percutaneous use?”


If this is the only vaccine administered, you should use code 90471, which covers immunization administration for a single or combination vaccine or toxoid.

A second opinion


What CPT code should I use for providing a state-mandated second opinion on the competency of a nursing-facility patient?


Assuming this service otherwise meets the definition of a consultation, you should probably use one of the five confirmatory consultation codes (99271–99275). Your choice will depend on the level of history, exam and medical decision making associated with the service. Since the consultation is required, you should also use a −32 modifier, “Mandated Services.” You should also keep in mind that, per CPT, “A physician consultant providing a confirmatory consultation is expected to provide an opinion and/or advice only. Any services subsequent to the opinion are coded at the appropriate level of office visit, established patient or subsequent hospital care.”

Care plan oversight


Can 99374 be used for completion of extensive forms for a patient who is in or being placed in a nursing home? There is no patient contact; we are only reviewing information and documentation from our records and completing a form from that information.


Per CPT, code 99374 may not be used for nursing-facility patients. It is specifically for care plan oversight of a patient “under care of home health agency.” However, two codes are designated for care plan oversight of nursing facility patients: 99379 and 99380. Like 99374, these two codes cover “regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) with other health care professionals involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy … .”

Routine venipuncture with office visit codes


What is the code for routine venipuncture, and can we code an office visit in addition to it?


The code, which also covers finger- heel- or ear-stick, is 36415*. This is a “starred” procedure in CPT, which means that if the routine venipuncture is done at the time of an established patient visit and the routine venipuncture constitutes the major service at the visit (e.g., the patient is present simply to have his or her blood drawn), you should not code an office visit in addition to 36415. If routine venipuncture is performed at the time of a new patient visit and it constitutes the major service at the visit, then you should use the miscellaneous services code 99025 instead of an office visit code.

Finally, you may code both an office visit and routine venipuncture at the time of any visit involving other significant, identifiable services (e.g., at the time of a comprehensive history and physical examination).

Fetal non-stress test


What is the CPT code for a fetal non-stress test?


It's 59025. If you are providing only the physician component of this service, consider attaching a −26 modifier, “Professional Component.”

Pre-op EKG


What diagnosis code should I use for an EKG done as part of a preoperative evaluation of a patient?


V72.81, “Pre-operative cardiovascular examination.”


In the July/August 1999 installment of this department, I concurred with a reader's use of a −52 modifier with a preventive medicine visit code “when the visit is an abbreviated screening visit.” I have since learned that it is not appropriate, from a CPT perspective, to add a −52 modifier to a preventive medicine visit code. I apologize for any confusion this may have caused.

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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