CODING & DOCUMENTATION
Answers to Your Questions
Fam Pract Manag. 2005 May;12(5):27-31.
- Diagnosis code for prescriptions
- V code for well-child visit
- Colonoscopy consult
- Latent tuberculosis
- Face-to-face requirements for E/M visits
- Exam for a prospective adoptive parent
- Allergen immunotherapy units
- Fecal-occult blood tests
Diagnosis code for prescriptions
What is the proper diagnosis code for patients who come in just for prescriptions?
Code V68.1 is for “Issue of repeat prescriptions.” This does not include a repeat prescription for contraceptives. For that you should choose the appropriate code from the series V25.41-V25.49. You should also code the diagnosis for the condition for which the prescription is issued.
V code for well-child visit
What V code can I use for a well-child visit with a 17-year- old patient? I have tried V70.0, and the insurance carrier denies it.
Try V20.2, “Routine infant or child health check.” ICD-9 designates this as a pediatric age code, which covers children up through 17 years of age.
A family physician in my office performs colonoscopies. He sees my patients in the office for screening prior to the procedure. How should we code these services?
Your colleague is providing two services. The first is the colonoscopy itself. According to CPT, colonoscopy, whether diagnostic or screening in nature, would typically be coded with 45378, “Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure).” Medicare, of course, has its own codes for screening colonoscopies: G0105 for individuals at high risk and G0121 for other Medicare beneficiaries. For screening colonoscopy, use an appropriate diagnosis code (e.g., V76.51, “Special screening for malignant neoplasms; intestine; colon”) to reflect the screening nature of the service. For diagnostic colonoscopy, use a diagnosis code that reflects the pertinent findings of the procedure or the symptoms that prompted it.
The other service you asked about is an evaluation and management (E/M) service. If it is not significant and separately identifiable from the evaluation/exam typically done prior to a colonoscopy, your colleague should not report it separately. If it is significant and separately identifiable, then he can code it as either a consultation or an office/outpatient visit. Whether he can code it as a consultation will depend on whether you have requested his advice or opinion regarding evaluation and/or management of a specific problem and whether he provides you, as the requesting physician, with a written report in return. It may also depend on your business relationship with him. Some payers do not recognize consultations between physician partners or physicians of the same specialty in the same group practice. If the E/M service is significant and separately reportable and otherwise does not meet the definition of a consultation, the office encounter should be coded using an office/outpatient visit code, such as 99213. In either case, modifier -25 should be appended to the E/M code to indicate that it was a significant, separately identifiable service from the colonoscopy done on the same date.
What is the best ICD-9 code to use for latent tuberculosis (i.e., positive PPD and negative chest x-ray)? Code 795.5 for positive PPD doesn't seem sufficient. Would 010.91, “Primary TB infection unspecified, bacteriological or histological examination not done,” be better?
There is no ICD-9 code explicitly for “latent tuberculosis.” However, 795.5 may be more sufficient than it seems at first. In the 2005 ICD-9 book, 795.5 is described as “Nonspecific reaction to tuberculin skin test without active tuberculosis.” Otherwise, as you suggested, you may be left with a non-specific code, such as 010.91.
Face-to-face requirements for E/M visits
Is the actual face-to-face contact with a patient necessary to determine the level of E/M coding, or is it just a guideline to be used in conjunction with the level of complexity of the visit?
Actual face-to-face time between the patient and the physician is generally not used to determine the level of service. Rather, it is the level of history, exam and medical decision making that governs code selection in most instances. One exception to this is an office visit where counseling and/or coordination of care consume more than 50 percent of the physician-patient encounter. In that situation, it is appropriate to code based on the total time the physician spent with the patient, rather than the history, exam and medical decision making involved. (For more information regarding when it is appropriate to code on the basis of time, see “Time Is of the Essence: Coding on the Basis of Time for Physician Services,” FPM, June 2003, page 27.)
Exam for a prospective adoptive parent
What is the appropriate CPT code for the physical exam and forms completion I provide for a patient who is applying to adopt a child?
Because the exam is administrative and not problem-focused, you should consider using one of the preventive medicine codes, 99381-99397. Alternatively, you can use a regular office/outpatient visit code (99201-99215). In either case, as appropriate, you may want to code 99080, “Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form,” in addition for the necessary form completion. You may also want to add modifier -32, “Mandated Services.”
Allergen immunotherapy units
For code 95117, “Professional services for allergen immunotherapy not including provision of allergenic extracts; two or more injections,” what do we put in the “units” field on the claim form?
You should only put “1” on the claim form, because one unit of service in this case includes “two or more injections.”
Fecal-occult blood tests
I have a number of questions about how to code appropriately for a fecal-occult blood test:
What CPT codes should be submitted when this test is done on non-Medicare patients with commercial health plans?
Does it make a difference in the coding whether the test is done for diagnostic or screening purposes?
How should the test be coded differently for Medicare patients?
Can we submit a code for the test even if it's done without an office visit, or does the patient have to review the card with the physician?
If the physician does one test with the patient in the office and then the patient collects another sample at home and mails it in for another test, can we code the test twice?
There are two CPT codes for fecal-occult blood tests: 82270, “Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, 1–3 simultaneous determinations,” and 82274, “Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1–3 simultaneous determinations.”
For most payers other than Medicare, either code may be used for screening or diagnostic tests. The purpose of the test should be indicated by the ICD-9 code that accompanies the CPT code on the claim form. If the test is done for screening purposes (e.g., for colorectal cancer), you should submit the appropriate ICD-9 code from the V76 series (e.g., V76.41, “Special screening for malignant neoplasms; other sites; rectum,” or V76.51, “Special screening for malignant neoplasms; intestine; colon”). If the test is done for diagnostic purposes, you should submit the appropriate ICD-9 code for the sign or symptom that prompted you to order the test.
Medicare considers CPT code 82270 to be a diagnostic test rather than a screening test. So, for fecal-occult screening tests, Medicare has its own code, G0107, “Colorectal cancer screening; fecal-occult blood test, 1–3 simultaneous determinations,” which is reimbursed once every 12 months. Note that with G0107, the patient must take the cards home, obtain samples and return them to you before the coverage criteria described in the Medicare Carriers Manual is met: “Screening fecal-occult blood test means a guaiac-based test for peroxidase activity, in which the beneficiary completes it by taking samples from two different sites of three consecutive stools.” Obtaining one specimen during the annual exam is insufficient for G0107.
A fecal-occult blood test may be billed independent of an office visit. For example, a patient presents for an office visit and is given a sample collection card to take home on June 1; that same day, a claim for the office visit is filed. On June 4, the completed card is returned and the test is done. It would be appropriate to submit a separate claim on June 4 for just the fecal-occult blood test.
Finally, if you perform one test in the office and the patient collects another sample at home and mails it in for another test, the appropriate CPT code for the test may be submitted twice – once for the date the test was done in the office and once for the date the test was done with the returned sample. In this scenario, the determinations are not simultaneous (i.e., not done at the same time) as called for in the code descriptors, so each determination represents a separate instance of the test. Note, however, that no codes may be submitted before a specimen(s) has been returned and analyzed. Simply providing a patient with a set of specimen collection cards is not sufficient for coding purposes. Also be aware this does not apply to Medicare screening tests as noted above.
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.
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Send questions and comments to firstname.lastname@example.org, 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 © 2005 by the American Academy of Family Physicians.
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