Answers to Your Questions


Fam Pract Manag. 2005 Jul-Aug;12(7):24.

Decision making and 99215


The 1997 version of Medicare's Documentation Guidelines for Evaluation and Management Services states that the code for an established patient visit can be based on two of the three key components. But if I perform a comprehensive history and a comprehensive physical, wouldn't medical decision making of high complexity also be necessary to code a 99215?


CPT states that “For the following categories/subcategories, two of the three key components (i.e., history, examination and medical decision making) must meet or exceed the stated requirements to qualify for a particular level of E/M services.” However, it also states under 99215 that “Usually, the presenting problem(s) are of moderate to high severity.” Although high complexity medical decision making isn't required, it's reasonable to conclude that this level of service may be questioned if it's not present. The Medicare Claims Processing Manual reminds us that “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code.”

Billing separate services for ob patients


When treating a pregnant patient for asthma unrelated to her pregnancy, can I bill separately for the asthma-related services?


Yes. The instructions in the Maternity Care and Delivery section of CPT state that “Antepartum care includes the initial and subsequent history, physical examinations, recording of weight, blood pressures, fetal heart tones, routine chemical urinalysis, and monthly visits up to 28 weeks gestation, biweekly visits to 36 weeks gestation, and weekly visits until delivery. Any other visits or services within this time period should be coded separately.”

Immune globulin injections


I recently administered rabies prophylaxis treatment, which includes the standard series of intramuscular vaccine injections and immune globulin injections around the bite sites. How should I code the injection of the immune globulin?


You should report the administration of the immune globulin using either 90782 or G0351, as indicated in the note at the beginning of the immune globulins codes (90281-90399) section in CPT. Use the appropriate code from the immune globulins section to report the immune globulin product (90375-90376).

Dilated eye exams


What are the guidelines for dilated retinal eye exams, and how should we code them?


The guidelines for intermediate ophthalmological services were revised in CPT 1998 to include the verbiage “for ophthalmoscopy.” According to CPT Assistant of August 1998: “This was done to clarify the use of mydriasis for ophthalmoscopy. Mydriasis is the increase in pupil size that normally occurs in the dark or artificially through the use of drugs. To facilitate ophthalmoscopy, the physician may utilize a mydriatic agent to dilate the pupils to help the physician better visualize the ocular media and fundus. The use of mydriasis for ophthalmoscopy is included in the intermediate ophthalmological services and is not normally a separately reportable service.”

To code services like these, you should use the ophthalmological services code (92002–92014) that best describes the service you provided. Depending on the situation, an E/M code may be the best choice.

Cindy Hughes is the coding and compliance specialist for the AAFP. 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, CCS-P; Thomas A. Felger, MD, DABFP, 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 and useful information, third-party payers may not accept the coding and documentation recommended. Refer to the current CPT and ICD-9 manuals and the Documentation Guidelines for E/M 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 © 2005 by the American Academy of Family Physicians.
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