Answers to Your Questions


Fam Pract Manag. 2002 Jul-Aug;9(7):22.

ER procedures and admission


I saw a patient in the ED, performed certain diagnostic procedures and then admitted him to the hospital based on the results. I know the work done in the ED is included in the hospital admission code, but are procedures included too? What about critical care?


As you noted, when a patient is admitted to the hospital in the course of an encounter in the ED, all evaluation and management (E/M) services provided by the physician in conjunction with that admission are considered part of the initial hospital care when done on the same date as the admission. The admitting physician should report the initial hospital care code (99221–99223) that reflects the work of the admission and the E/M services that were provided in the ED and related to the admission.

The actual performance and/or interpretation of diagnostic tests/studies ordered during initial hospital care or ED services are not included in the level of E/M service. So, for example, if you do an EKG interpretation and report (e.g., 93010), it may be coded separately.

Critical care and other E/M services may be provided to the same patient on the same date by the same physician. So, if you provide critical care to a patient on the same date as either an emergency visit or a hospital admission, the critical care may be reported separately. However, critical care does include certain services (e.g., chest X-ray interpretation) that are otherwise separately reportable but may not be separately coded when done during the critical period by the physician providing critical care. These services are listed in CPT. The amount of time spent in critical care should be documented in the patient record, and the duration of critical care must be at least 30 minutes to be coded separately.

Billing for nursing home work


For my nursing home patients, I would like to bill for the time it takes me to answer the staff’s questions, write the orders and do all of the paperwork for the patients. Although Medicare has care plan oversight codes, apparently these activities are not billable for nursing home patients. Is there any other way I can bill for this time-consuming care?


Unfortunately, no. Medicare takes the position that payment for care plan oversight services provided to nursing facility patients is already bundled into the payment it makes for the nursing facility visits and other E/M services provided to these patients. Because Medicare views these services as “bundled,” it does not permit the physician to separately bill the patient for them.

Removing a nuchal lipoma


What code should I submit for the removal of a nuchal lipoma?


Lipomas are typically benign tumors commonly found in superficial tissue, although they can also be present in subfascial and sub-muscular locations. If you excise the nuchal lipoma from the skin, you should use the appropriate code in the series 11420–11426, “Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia.” If the lipoma is subcutaneous, you should use either the appropriate code in the series 11420–11426 or 21555, “Excision tumor, soft tissue of neck or thorax; subcutaneous,” since both options address excision of a subcutaneous lesion/tumor. Finally, for removal of a nuchal lipoma from deep, subfascial or submuscular tissues, use 21556, “Excision tumor, soft tissue of neck or thorax; deep, subfascial, intramuscular.”

Kent Moore is the AAFP’s manager for health care financing and delivery systems and is a contributing editor to Family Practice Management. These questions and answers were reviewed by members of the FPM Coding & Documentation Review Panel, which includes: Robert H. Bosl, MD, FAAFP; Marie Felger, CPC; Thomas A. Felger, MD, ABFP, CMCM; David Filipi, MD, MBA, and the Coding and Compliance Department of Physicians Clinic; Lynn Handy, CPC, LPN; Emily Hill, PA-C; Joy Newby, LPN, CPC; P. Lynn Sallings, CPC; and Susan Welsh, CPC.

Conflicts of interest: none reported.

Editor’s note: While this department attempts to provide accurate information and useful advice, third-party payers may not accept the coding and documentation recommended. 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 © 2002 by the American Academy of Family Physicians.
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