Coding and Documentation

Answers to Your Questions


Fam Pract Manag. 2000 Apr;7(4):16.

Emergency visits


We've had an ongoing problem determining the appropriate code for same-day sick patients. Should they be treated as emergencies?


By “same-day sick patients,” I assume you mean patients who contact the office for an appointment and are seen that same day because of their illness. I do not believe you should automatically treat such encounters as emergencies for CPT purposes.

“Same-day sick patients” seen in the office should generally be coded using office visit codes (e.g., 99201–99215). If you believe, however, that the situation is indeed an emergency, you may code 99058, “Office services provided on an emergency basis,” in addition the office visit code.

Per CPT, the emergency department services codes (e.g., 99281–99285) are used to report evaluation and management (E/M) services provided in the emergency department, which CPT defines as “an organized hospital-based facility for the provision of unscheduled episodic services to patients who present for immediate medical attention. The facility must be available 24 hours a day.”

Pre-op services only


What is the proper way to code and document a pre-surgery history and physical examination on your own patient? Can I bill the CPT of the surgeon with a –56 modifier? Or, if the examination and report are requested by the surgeon, is a consultation code appropriate?


You are correct that if the surgeon a report is made back to the surgeon, this generally qualifies as a consultation on the part of the family physician and should be reported as such. Otherwise, as noted, if the family physician is providing preoperative care and evaluation for a patient undergoing surgery by another physician, the family physician can add modifier –56, “Preoperative management only,” to the procedure code for the surgery.

Post-op services only


How can we indicate when billing for our services that one physician performed the surgical procedure and another provided the postoperative management?


The surgeon can attach modifier –54, “Surgical care only,” to the surgical service code, and the physician providing postoperative management can attach modifier –55, “Postoperative management only,” to the same code.

DOT physicals


What diagnosis code should I use for Department of Transportation (DOT) physicals?


I would use one of two diagnosis codes, depending on the purpose of the physical. If the purpose is to obtain a driver's license, I would use V70.3, “Other medical examination for administrative purposes,” which includes getting a driver's license. If the physical is for employment purposes (e.g., so the patient can be certified to drive for a trucking firm), I'd use V70.5, “Health examination of defined subpopulation,” which includes pre-employment screening.

Delivery by an RN


An obstetrics patient is admitted and delivers with only a nurse present. The family physician delivers the placenta and reviews the case, which is without complications. Can the physician bill for the entire delivery or for the placenta delivery only?


I would suggest that the family physician bill only for the delivery of the placenta (i.e., code 59414). If the physician goes on to provide postpartum care, he or she may also bill code 59430, “Postpartum care only (separate procedure).”

Blood glucose monitoring


Can we code 82962, “Glucose, blood by glucose monitoring device(s) cleared by the FDA specifically for home use,” when we use a home device in the office? If the insurer will not pay for code 82962, can we use 82947, “Glucose; quantitative” or 82948, “Glucose; blood, reagent strip,” instead?


Yes, you may use 82962 when using the device in question in the office. But you should not use 82947 or 82948 to represent 82962, since these codes represent different tests.

Coding Pap smears separately


When doing an annual physical that includes a Pap smear, can the physician charge for a comprehensive exam as well as the Pap smear?


Yes. According to CPT, the performance and/or interpretation of diagnostic tests and studies ordered during a patient encounter are not included in the E/M service code, and “physician performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code.”

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 is a contributing editor to Family Practice Management.


Copyright © 2000 by the American Academy of Family Physicians.
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