Coding and Documentation

Answers to Your Questions


Fam Pract Manag. 2000 May;7(5):22.

Follow-up visits


A great deal of what family physicians do involves following up on patients' problems. For example, let's say a patient of mine was treated for three problems on the previous visit and now comes to me for follow-up. During the visit, I ask the patient about these problems, and she tells me they're all resolved. How do I code for such a visit? And how would I code it if the patient came in only for refills on meds and I did nothing else on that visit?


Follow-up visits, like initial visits, should be coded using the appropriate evaluation and management (E/M) code (i.e., 99211–99215). Given the limited interaction with the patient and limited work involved, the level of service is likely to be low (e.g., 99211 or 99212). For instance, the three-problem follow-up you cited may involve at least a problem-focused history, given the brief history of the present illness(es), and some straightforward medical decision making; that's enough to qualify it as a 99212. Even if there is no history, exam or medical decision making involved (as in the prescription refill example), you can always code the encounter as a 99211.

Alternative modifiers


If an insurer doesn't recognize CPT's two-digit modifiers, is there another way to communicate that information?


Yes. The alternative to adding a two-digit modifier to the appropriate CPT code is to code the five-digit version of the modifier in addition to the CPT code. For example, instead of coding 99213–25, you can code 99213 and 09925. The five-digit version of a CPT modifier is always 099XX, with “XX” being the two digits otherwise associated with the modifier.

Inconclusive diagnoses


What ICD-9 code should I use for a skin biopsy sent to the lab when I do not know exactly what the problem is?


When you do not have a definitive diagnosis for a service, it is usually recommended that you base your code selection on the signs or symptoms that prompted the service. [See “Improve Your ICD-9 Coding Accuracy,” July/August 1999] In this case, an ICD-9 code in the 782 series, “Symptoms involving skin and other integumentary tissue,” would probably be in order.

Inpatient for a day


Are there any codes for services provided to patients admitted to and discharged from the hospital on the same date?


Yes. CPT codes 99234–99236 are for observation or inpatient hospital care services provided to patients admitted and discharged on the same date of service.

Complementary medicine


I practice complementary medicine: I advise patients about herbs, vitamins, lifestyle changes and nutrition, and I teach relaxation techniques. What CPT codes do I use?


I believe this fits the CPT definition of “counseling,” which includes risk-factor reduction and patient education. How you code this counseling will depend on whether it is directed at a particular symptom or established illness. If you are counseling an individual patient with symptoms or an established illness, you should use the appropriate office visit code (i.e., 99201-99215), assuming this is done in the office. Note that if the counseling consumes more than half of the face-to-face time, you may code on the basis of the total time involved.

If the counseling is not directed at a particular symptom or established illness (i.e., it's preventive in nature) and you do it at a separate encounter (i.e., it's not done in conjunction with a preventive medicine visit, 99381-99397), then you may use one of the preventive medicine individual counseling codes, 99401–99404, based on the time spent with the patient. If the preventive medicine counseling is done in conjunction with a preventive medicine visit, then the counseling is simply part of the visit code.

Subsequent hospital care


I recently assumed responsibility for the care of a hospitalized patient of mine who had been admitted following treatment in the emergency department by an emergency physician and a surgeon. The hospital requires family physicians to assume responsibility for their patients' hospital care in such cases. Should I use an inpatient consultation or subsequent hospital care code to bill for this service?


Use one of the subsequent hospital actually assuming care of the patient and the service does not appear to fit CPT's definition of a consultation: “A type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or appropriate source.”

Editor's note: While this department represents our best efforts to provide accurate information and useful advice, we cannot 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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