Coding and Documentation

Answers to Your Questions


Fam Pract Manag. 2000 Nov-Dec;7(10):17.

Mental status assessment


What CPT code should I use for the assessment of mental status through the administration of standardized instruments?


The series of CPT codes from 96100 to 96117 are “used to report the services provided during testing of cognitive function of the central nervous system,” according to CPT. A number of these codes reference standardized assessment instruments in their descriptors.

Telephone care


Our family practice group would like to begin charging for the medical care we deliver by telephone. We have developed protocols for certain conditions that can be treated over the phone and studied our results of efficacy and patient satisfaction. We also anticipate delivering some care using the Internet and e-mail. What codes can we use for these services?


CPT codes 99371–99373 cover a “telephone call by a physician to patient or for consultation or medical management or for coordinating medical management with other health care professionals.” However, Medicare considers telephone care to be part of the E/M service covered by the office visit codes and does not provide separate reimbursement for it, and many commercial payers follow Medicare's lead. There are no CPT codes for Internet or e-mail communication with patients. You should contact representatives of the health plans you contract with to discuss their reimbursement policies for all three types of service.

Postoperative management only


How would the physicians in the following scenario code their respective services? A surgeon provides an inpatient surgical procedure with a 90-day global period as well as the outpatient post-op care. A family physician provides the inpatient post-op care following the surgery because the surgeon is from out of town and spends just one day a week in the patient's rural community.


The family physician providing the post-op care in the hospital should submit the CPT code for the surgical procedure with a -55 modifier (postoperative management only) and indicate the date(s) of service of postoperative management. The surgeon will need to bill the surgical procedure code but indicate that he or she did not provide the entire global package.

Defining risk


The table of risk in Medicare's “Documentation Guidelines for Evaluation and Management (E/M) Services,” lists “prescription drug management” in the moderate risk category. I believe this term would cover making a change in a prescribed medicine, but does it also cover making a decision to continue a patient's prescription drug regimen? Likewise, “drug therapy requiring intensive monitoring for toxicity” is listed in the high risk category. I believe this would include checking an INR for a patient on Coumadin, but what other medications and tests might be applicable?


Neither the table of risk nor any other part of the documentation guidelines define what “prescription drug management” or “drug therapy requiring intensive monitoring for toxicity” mean. A decision to continue a particular medication might be considered “prescription drug management” since you would be managing the patient's prescription medicine and since a decision to continue a patient's current medication may involve as much risk as a decision to initiate a prescription drug regimen. But whether this example or the second one you gave would fit the descriptions of risk given in the table would be a matter of judgment for both you and any reviewer.

Defining HPI


Were chronic conditions addressed in the “History of Present Illness” (HPI) portion of the 1995 version of Medicare's E/M documentation guidelines?


No. The reference to chronic conditions was one of the changes incorporated in the 1997 version of the guidelines, which expanded the definition of an extended HPI to include “the status of at least three chronic or inactive conditions.”

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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