Coding and Documentation

Answers to Your Questions


Fam Pract Manag. 2000 Mar;7(3):21.

Drug screens


What CPT code should I use for a drug screen?


The CPT codes for drug testing, including drug screens, are 80100 through 80103. Use the appropriate code for the particular drug screen you are doing.

Coding pelvic exams


If a patient comes into the office for a routine Pap smear and pelvic exam, should we bill for a “well visit exam” if there are no problems or abnormalities? If the patient is having abnormal bleeding, infection, etc., should we bill for an office visit? I have tried to use the G0101 code and have not had much success.


A routine pelvic exam done in the absence of any symptoms or established illness should be coded, as you suggested, using a well visit code (preventive medicine codes 99381-99397). According to CPT and Medicare, the exam of a patient presenting to the office with a problem should be coded using the appropriate evaluation and management (E/M) office visit code (99201-99215). The pelvic exam would be considered part of the medical exam portion of the office visit.

HCFA Common Procedure Coding System code G0101, “Cervical or vaginal cancer screening; pelvic and clinical breast exam,” is intended to be used with Medicare patients to whom such a service is provided, since it is a covered Medicare benefit and preventive medicine services are not. You may use G0101 with another E/M code if the E/M service is provided at the same encounter for different reasons; you'll also need to use a -25 modifier.

Suture removal


I am a family physician who moonlights in the emergency department. When a patient arrives with a laceration, I tell him or her to follow up in so many days in my office for the removal of the sutures. Can I charge a fee for removing the sutures in my office?


No. It would be inappropriate to separately code the suture removal since you put them in. According to CPT, “normal, uncomplicated follow-up care,” such as suture removal, is part of the surgical package (laceration repair, in your case). However, as we noted in the July/August 1999 issue, when a doctor removes sutures placed by another physician, he or she may use an office visit code (e.g., 99211) for the removal.

Preventive medicine


I would like to start a program of extensive nutritional and lifestyle counseling with a select group of patients who are at great medical risk due to their current habits. This will require multiple visits of close to an hour each. Is there a way to code these visits so that I can be properly reimbursed for my time?


Yes. Your statement that the patients are “at great medical risk due to their current habits,” suggests that the counseling you plan to provide is preventive rather than directed at current symptoms or established illnesses. If so, you can code these counseling sessions using the preventive medicine counseling codes for individuals (99401-99404) or groups (99411-99412), whichever is appropriate. Each set of codes is time-based. The code for individual counseling of approximately 60 minutes is 99404, and the corresponding code for group counseling is 99412.

If you are counseling individual patients with symptoms or established illnesses, CPT advises using the appropriate office visit code (99201-99215), assuming that the counseling is done in the office. Assuming counseling consumes more than half of the face-to-face time, you may select the office visit code on the basis of the total time involved. For counseling groups of patients with symptoms or established illnesses, use 99078.

ICD-9 code for a strained trapezius muscle


What diagnosis code should I use for a strain of the trapezius muscle?


The diagnosis codes for strains and sprains of joints and adjacent muscles are found in the series of ICD-9 codes 840-848. In this series, there is no code specifically for the trapezius muscle. Since the trapezius muscle covers the posterior surface of the neck and shoulder, you may want to use either 840.8, “Sprains and strains of shoulder and upper arm; other specified sites of shoulder and upper arm,” or 847.0, “Sprains and strains of other and unspecified parts of back; neck.” As a last resort, you might use 848.8, “Other and ill-defined sprains and strains; other specified sites of sprains and strains.”

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 health care financing and delivery systems and a contributing editor to Family Practice Management.


Copyright © 2000 by the American Academy of Family Physicians.
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