Coding and Documentation

Answers to Your Questions


Fam Pract Manag. 2000 Jun;7(6):16.

Allergy shots


What CPT code should I use for providing allergy shots that were concocted by an allergist and turned over to a patient who brought it to us to administer?


You should use code 95115 or 95117. Both of these codes cover the injection and exclude the provision or preparation of the extract. Code 95115 may be used for a single injection; 95117 covers two or more injections.

New patient definition


I am the sole family physician in a small multispecialty clinic. The only internal medicine physician is leaving, and many of her patients are scheduling appointments with me. Can I code these visits as new patient visits since I am in a different specialty?


Yes. CPT defines a new patient as “one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the last three years” (emphasis added).

H. pylori test


What CPT code should we use for an H. pylori test?


It depends on the nature of the test. For example, if you are doing a test for H. pylori antibodies, try86677, “Antibody; Helicobacter pylori.” However, if you are testing for the H. pylori agent itself, you might try 87338, “Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple step method; Helicobacter pylori, stool.” There are also codes for H. pylori breath tests. These include 83013, “ Helicobacter pylori, breath test analysis (mass spectrometry)”; and 83014, “ Helicobacter pylori, breath test analysis (mass spectrometry); drug administration and sample collection” as well as 78267, “Urea breath test, C-14; acquisition for analysis,” and 78268, “Urea breath test, C-14; analysis.”

Acupuncture and hypnosis


I do some hypnosis and acupuncture in my practice. What CPT codes should I use?


CPT offers a code for “hypnotherapy,” 90880. The AMA's Department of Coding and Nomenclature defined hypnotherapy in its CPT Assistant newsletter (Summer 1992:16) as “a treatment that makes use of an artificially induced alteration of consciousness characterized by increased suggestibility and receptivity to direction.” It may be used for diagnostic or therapeutic purposes. There are two codes for acupuncture: 97780 is for acupuncture using one or more needles, without electrical stimulation; 97781 is for acupuncture using one or more needles, with electrical stimulation.

Nonroutine venipuncture


What are the proper uses of CPT code 36410?


According to CPT, code 36410 is for venipuncture, performed on an individual over 3 years of age, that requires a physician's skill. It may be done for diagnostic or therapeutic purposes, and it is not considered “routine” venipuncture, which is coded with 36415.

Most common office visit codes


I've heard that the Health Care Financing Administration (HCFA) is more likely to audit a physician who falls outside the bell curve of office visits (for example, one who performs more level-V office visits than level-IIIs). What is the norm for family physicians?


The graph in the Monitor department shows the distribution of office visits for family physicians based on HCFA data. For a ranking of the 100 CPT codes most often used by family physicians, visit the AAFP Web site at

Heel pain diagnosis


What is the ICD-9 code for heel pain?


The most proximate code is 729.5, “Pain in limb.”

Waived tests


How should we indicate when we have used a Clinical Laboratory Improvement Amendments (CLIA) waived test?


Add the HCFA Current Procedural Coding System (HCPCS) modifier -QW, “CLIA waived test,” to the appropriate CPT laboratory code.

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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