Coding and Documentation

Answers to Your Questions


Fam Pract Manag. 2000 Sep;7(8):22-23.

Defining “self-limited problem”


What is a “self-limited or minor problem?”


CPT defines a “self-limited or minor” problem as one “that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status or has a good prognosis with management/compliance.” Examples in the documentation guidelines include a cold, an insect bite and tinea corporis.

When 99211 isn't appropriate


It has been my understanding that there needed to be some type of teaching, medication adjustment or physician consultation by the nurse for a 99211 claim to be reimbursable. If that's the case, it seems appropriate to use this code for allergy injections because our nurse observes the patient and checks the injection site for a period of time. However, would it be more appropriate to use an administration of injection code for a monthly B-12 injection?


Yes. If the patient received a B-12 injection only, it would not be appropriate to code 99211 because there was no evaluation and management (E/M) component to the visit. Instead, you should use an administration code in conjunction with a J code for the B-12 itself (90782 with J3420, for example).

Office visit + allergy vaccine injection?


Because I don't employ a nurse, I do allergy injections myself. Since I'm a physician providing this service, can we be reimbursed for 95115 and 99211?


If you are providing other identifiable services at the time of the allergen immunotherapy, it would be fine to submit the appropriate office visit code in addition to 95115. According to CPT, codes 95115-95199 “include the professional services necessary for allergen immunotherapy. Office visit codes may be used in addition to allergen immunotherapy if other identifiable services are provided at that time” [emphasis added]. In that instance, you may want to add modifier -25 to the office visit code.

Office visit + treadmill exam?


I documented a 99215 on a very complex patient with chest pain and shortness of breath. I also did a treadmill exam. How should I code it? If I bill the 99215 with the code for the treadmill exam, do I need to attach a –25 modifier to the 99215?


You could bill your 99215 and the appropriate code for the treadmill test without invoking the -25 modifier. According to CPT, “The actual performance and/or interpretation of diagnostic tests/studies ordered during a patient encounter are not included in the levels of E/M services. 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.”

Epoetin alpha for anemia


What code should I use to bill for EPO given for anemia?


HCPCS code Q0136, “Injection, epoetin alpha (for non-ESRD use), per 1,000 units,” is the code to use for EPO used to treat anemia in patients undergoing chemotherapy for non-myeloid malignancies.

Medical decision making score sheets


Are the widely published score sheets for medical decision making part of the E/M documentation guidelines? They're not included in the version of the guidelines I downloaded from the Health Care Financing Administration (HCFA) Web site.


Technically, the scoring is not part of the documentation guidelines. HCFA provided the score sheets to its Medicare carriers for reviewers' use in evaluating medical decision making documentation, since there is no objective way to do so using the guidelines themselves. HCFA did not mandate that carriers use the score sheets but did not prohibit them from using the sheets either. Carriers, in turn, have shared the score sheets with physicians as part of the carriers' educational efforts related to the guidelines, and publications including Family Practice Management have published the guidelines.1 Since carrier staff may be using the score sheets, it seems only appropriate that physicians be able to use them.

HCFA releases new Medicare documentation guidelines, plans pilot tests

The Health Care Financing Administration (HCFA) recently unveiled a draft version of the newest Medicare documentation guidelines for evaluation and management (E/M) services. HCFA Administrator Nancy-Ann DeParle says the guidelines have been simplified and, pending the results of pilot testing, could be in place as early as 2002.

HCFA used the original 1995 version of the guidelines as the basis for its latest draft when studies showed it enables more consistent, reliable medical review and greater work equivalency across specialties and deviates less from CPT definitions when compared with the 1997 guidelines and the version proposed in 1999. The revision is designed to minimize counting of elements, and will incorporate specialty-specific vignettes for physical exams and medical decision making.

HCFA plans to begin pilot testing in 2001. One test will place equal emphasis on all elements (i.e., history, exam and medical decision making), and a second test will place greater emphasis on medical decision making.

Until new guidelines are implemented, Medicare contractors will continue basing medical records review on either the 1995 or 1997 versions of the guidelines, whichever is most advantageous to the physician.


1. Edsall RL and Moore KJ. Thinking on paper: guidelines for documenting medical decision making. Fam Pract Manage. April 1995:49–60. The score sheets are incorporated in the Family Practice Management “Pocket Guide to the Documentation Guidelines.” The original pocket guide (item A-556) was published in the May 1995 issue of FPM, and a revised version(item A-557) was published in the January 1998 issue. To purchase either version, call the AAFP Order Department at 800-944-0000.

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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