Coding and Documentation

Answers to Your Questions


Fam Pract Manag. 1999 Nov-Dec;6(10):14.

Diagnostic tests and an office visit


We have a patient with a history of congestive heart failure who presented to the clinic with asthma and dyspnea on exertion. We did a chest X-ray, echocardiography and spirometry and provided a comprehensive office visit. Can we bill and get paid for these services using these diagnoses?


According to CPT, you can bill tests performed or interpreted in the course of a visit separately from the appropriate evaluation and management (E/M) code. Keep in mind, however, that reimbursement will depend on the payment policy of your patient's insurer.

Peak flow and an office visit


How should I code a follow-up office visit for asthma that includes peak-flow testing but not full spirometry?


Peak-flow rate is an inherent part of the E/M exam and should not be separately reported, according to CPT. So you should simply code the encounter using the appropriate established-patient office visit code.

Coding multiple simultaneous determinations


Please provide clarification of 82270, “Blood, occult; feces, 1–3 simultaneous determinations.” For three determinations, should I code 82270 once or three times?


The term “simultaneous” refers to the placement of the developing solution used to obtain the interpretation of occult blood in the fecal specimen(s). Thus, if all three determinations are done at the same time, code 82270 once. If not, code it once for each date of testing.

Diagnosis code for ADD


What is the diagnosis code for attention deficit disorder?


The basic ICD-9 code is 314.0, “Attention deficit disorder.” Please note that this code requires a fifth digit to indicate either “without mention of hyperactivity” (314.00) or “with hyperactivity” (314.01). These codes cover both adults and children.

Global surgical service exclusions


In the July/August 1999 issue, you recommended using an office visit code for in-office removal of sutures placed by another physician. Even if another doctor provided the original service, wouldn't suture removal be considered a part of the global surgical service and as such not be reimbursable to the physician removing the sutures since he would have no diagnosis to make this a separate, identifiable E/M service?


Suture removal is generally included in the global surgical package if the removal is done by the physician who performed the surgery. However, the global surgical package excludes services of other physicians and would therefore exclude suture removal in this case. Incidentally, there is a diagnosis code that covers suture removal: V58.3, “Attention to surgical dressings and sutures,” includes change of dressings and removal of sutures.

Chronic conditions and prevention in one exam


We perform yearly comprehensive exams in which we mostly discuss and review patients' chronic medical conditions such as diabetes, hypertension and CHF. We also discuss prevention of osteoporosis, colon cancer, cholesterol problems, etc. How should we code these visits, and do the rules vary depending on the age of the patient?


If the primary purpose of the annual visit is to address the status and management of the patient's chronic conditions, such that these are the primary diagnoses on the claim form, you should use the usual office visit codes (assuming the services are provided in the office). The discussion of preventive medical issues, which is incidental to the encounter, would fall within the counseling component of the CPT codes for office visits, which includes “risk factor reduction” and “patient and family education.”

You should choose the appropriate office visit code based on the level of history, exam and medical decision making involved, or if counseling consumed more than half of the face-to-face time, you should choose the office visit code that corresponds to the total time involved. In either case, the age of the patient should not affect the coding.

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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