Coding and Documentation

Answers to Your Questions


Fam Pract Manag. 2000 Jul-Aug;7(7):23.

Visit + procedure


Can we charge for an office visit at the same time we charge for a procedure, such as a lesion removal, if the provider feels he or she performed the evaluation and management (E/M) service? I saw and removed a carbuncle on a same-day appointment.


From a CPT perspective, most procedural services include a certain E/M component. So you should not report an E/M code with a procedural service unless the E/M service was “significant and separately identifiable.” If you did the key components of an E/M service in addition to removing the carbuncle, I believe that you could report the code for carbuncle removal as well as an E/M code with modifier -25 attached. Note that “significant, separately identifiable” does not necessarily mean unrelated. As CPT notes, “the E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided.”



In the October 1999 issue (page 16), you explained that code 99211 is appropriate for use when a patient is given an injection by a nurse, seen for a blood pressure check or given an allergy injection. Doesn't the physician need to be present to use this code?


All of the examples cited in the October article correspond to clinical examples given for 99211 in Appendix D of the CPT book. According to CPT, 99211 “may not require the presence of a physician.” This means, from a CPT perspective, the physician does not need to see the patient for this service to be coded. (See the related article on page 39.)

ICD-9 for multiple myeloma


What is the diagnosis code for multiple myeloma?


Diagnosis code 203.00 is for “multiple myeloma without mention of remission,” and 203.01 is for “multiple myeloma and immunoproliferative neoplasms in remission.”

“New problem”


For purposes of Medicare's “Documentation Guidelines for Evaluation and Management Services,” are first episodes of an upper respiratory infection (URI), urinary tract infection (UTI), strains/sprains, etc. new problems? Is a second episode an established problem, even if the first episode was more than one year ago?


The documentation guidelines speak in terms of presenting problems “with or without an established diagnosis.” First episodes of a URI, UTI, etc. would likely be considered a new problem to both the patient and the physician, since they would not be an established diagnosis to either. The second episode would also likely be a new problem, especially when separated by a long amount of time.

I believe the term “problem with an established diagnosis” tends to refer either to a chronic condition or an acute condition within a given episode of care. For example, if you had an initial patient visit in which you diagnosed the URI and a follow-up visit two weeks later, then the URI at the initial visit would be a new problem while the same URI at the follow-up visit would be an established problem, since it had been previously diagnosed. If the patient comes back a year later with a new case of URI, it would constitute a new problem.

Lab specimen transportation


Can you explain the proper use of CPT code 99000? How does it relate to specimen collection, lab codes and venipuncture?


CPT code 99000, “Handling and/or conveyance of specimen for transfer from the physician's office to a laboratory,” is intended to be reported when the practice incurs costs to handle and/or transport a specimen to a lab. For example, if the practice employs a messenger service to transport a specimen, that service can be coded using 99000. In comparison, if lab staff pick up a specimen at no additional cost to the practice, it would not be appropriate to report code 99000.

Code 99000 also is not intended for reporting the obtaining of a specimen. Reimbursement for obtaining a Pap smear or a throat culture is factored into the relevant lab procedure code. Obtaining a blood specimen by venipuncture may be reported separately, using code 36415, “Routine venipuncture or finger/heel/ear stick for collection of specimen(s).”

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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