Answers to Your Questions


Fam Pract Manag. 2001 Apr;8(4):16.

Documenting a level-V visit


At a recent evaluation and management (E/M) coding seminar, I was instructed that a level-V code is essentially unobtainable unless the patient has an acute, severe medical condition. The consultant said, “No matter what is documented in reference to history, examination or complexity of decision making, you could not reach level-V care unless the risk requirements were met.” This advice seems contrary to what I've read in FPM, especially as it pertains to an established patient. It is not rare to have an elderly patient come into the office with diabetes, hypertension, coronary artery disease and a new onset of dizziness or fatigue. The work-up requires level-V history and level-V decision making, but the risk is not level-V.


I believe your consultant is incorrect with respect to an established patient office visit. Per CPT, a level-V established patient office visit (99215) requires two of the following three key components: comprehensive history, comprehensive examination and medical decision making of high complexity. Thus, if your history and examination were both comprehensive, you could code a 99215, even if the low risk associated with the service prevented you from documenting medical decision making of high complexity.

A level-V new patient visit (99205) does require all three elements, so if the encounter does not represent medical decision making of high complexity, a level-V would not be obtainable, even if the history and examination were comprehensive.

You should keep the separate issue of “medical necessity” in mind as well. Even where a level-V visit is properly documented and coded, it may be determined that the service was not medically necessary and, therefore, not reimbursable. The classic example is the patient who presents with a simple cold and no other conditions, chronic or otherwise. While it is possible to provide, document and code a level-V visit for such a patient, it is hard to imagine anyone agreeing that such a level of service was appropriate given the patient's presenting problem.

The risk of prescription drug management


According to the table of risk in the documentation guidelines for E/M services, prescription drug management is associated with a moderate level of risk. How many prescriptions must you be dealing with to meet this guideline?


The documentation guidelines do not specify the number of prescriptions involved with a moderate level of risk, so one must assume that managing even one prescription drug would qualify the level of risk as moderate.

Urinalysis in OB care


Is urinalysis included in the antepartum care component of maternity care?


Yes. Per CPT, “routine chemical urinalysis” is included.

Fluorescein staining


Is there a separate CPT code for fluorescein staining done for corneal abrasion as part of an office visit?


No. This appears to be part of any E/M service or general ophthalmologic service provided to the patient.

90862 + E/M code?


Could I be reimbursed for an E/M code in addition to 90862 (“Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy”) if we attach modifier −25 to the E/M office visit code? Here's an example: A patient comes in for his scheduled visit for depression medicine but wants to be seen for an acute upper respiratory infection at the same time.


No. The pharmacologic management would be considered part of the E/M service, so it would not be appropriate to submit both codes. In your example, you should submit the office visit code that accounts for the pharmacologic management as well as the other E/M services provided at that encounter.

Kent Moore is the AAFP's manager for health care financing and delivery systems and is a contributing editor to Family Practice Management.

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. Because CPT and ICD-9 codes change annually, you should refer to the current CPT and ICD-9 manuals and the “Documentation Guidelines for Evaluation and Management Services” for the most detailed and up-to-date information.



Send questions and comments to, or add your comments below. While this department attempts to provide accurate information, some payers may not accept the advice given. Refer to the current CPT and ICD-10 coding manuals and payer policies.


Copyright © 2001 by the American Academy of Family Physicians.
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