Fam Pract Manag. 2006 Apr;13(4):31-32.

List the chief diagnosis code first


I recently saw a patient for a complete physical. She complained of pain in the joints of her hands and bursitis in her hip. Which diagnosis code should I list first? Does it have to be V70.0, “Routine general medical examination at a health care facility”?


The guidelines for ICD-9 coding state: “List first the ICD-9-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions.” You must determine which condition was chiefly responsible for the services you provided and list this diagnosis code first. List the additional diagnoses, linking each to the related CPT code. In your example, you should link V70.0 to the preventive medicine services, and link the diagnosis codes for hand pain and bursitis to the problem-oriented evaluation and management (E/M) code, if the work was significant to warrant billing separately for it.

Consultation or subsequent care in hospital rehab unit?


A rehabilitation physician has requested my consultation for management of problems such as hypertension and diabetes. His patients are in the acute rehab unit of the hospital and have no other primary care physician. He is recognized as the attending. How should I code these patient encounters?


If the hospital bills rehab unit services as inpatient care, then your services are inpatient care. If the hospital bills them as nursing facility care, then your services are nursing facility care.

To bill a consultation, the rehab physician must have requested your advice or opinion on the management of the patient rather than asking you to assume management of the patient’s care.

For inpatient consultations, including those in a nursing facility, see codes 99251–99255. For inpatient care other than consultations or follow-up consultations, see the subsequent hospital care codes (99231–99233). For subsequent nursing facility care other than consultations or follow-up consultations, see the subsequent nursing facility care codes (99307–99310).

New vs. established patients


I am a third-year family medicine resident who will be starting work at an established clinic. I will be the only doctor in this clinic. Currently there is a part-time internist working there, but he will leave when I arrive. Can I bill everyone I see as a “new patient” because they are all new to me?


In a group practice in which physicians’ services are billed under one tax identification number, a patient is new if no physician of the same specialty has had a face-to-face encounter with the patient in the past three years. According to this definition, which is from Medicare’s Documentation Guidelines for Evaluation and Management Services, the patients are new to you – assuming the internist has been the only physician in the group for the last three years. Keep in mind that some payers may not differentiate between the primary care specialties when determining new versus established, so you should check with the health plans you contract with to determine whether it’s worth the trouble to make the distinction. Only two out of three key components are required for coding established patient visits whereas all three – history, exam and decision making – are needed for new patient visits. Some patients may not understand being designated as “new” patient and having to pay a higher fee, so be prepared to explain the policy.



I am considering incorporating acupuncture into my practice. How should I code these services, particularly for Medicare or Medicaid patients?


Medicare does not cover acupuncture, and few state Medicaid programs cover it. You would need to check with your state Medicaid program to be sure of coverage for your services. Medicare beneficiaries may ask you to file a claim to Medicare because the rejection may allow them to file the claim with another insurance company. Because Medicare never covers the service, you do not need to obtain an advance beneficiary notice; however, you may want to obtain a Notice of Exclusion From Medicare Benefits (NEMB) for your records. The NEMB form can be found online at The acupuncture codes are 97810–97814 and are reported based on 15-minute increments of face-to-face time with the patient.



What is the correct code for a 90-minute psychotherapy session?


You should bill 90808 for 90 minutes of psychotherapy alone, or 90809 if E/M services are included, with modifier -22 appended to your CPT code. You could use the narrative field of your claim form to report the time. Modifiers -22 (unusual procedural services) and -52 (reduced services) may be used to report psychotherapy time that falls outside the times stated in the psychotherapy codes 90804–90809.

Managing home INR draws


We have many patients in our practice who monitor their prothrombin time/international normalized ratios (INR) levels at home. We track these results by phone and make dosage changes as needed. Can we bill for this?


I would recommend contacting your payers to find out. For Medicare patients with mechanical heart valves, the answer is yes. In such cases, Medicare allows physicians to bill G0250 for review and interpretation of the INR results from home: “Physician review, interpretation and patient management of home INR testing for a patient with mechanical heart valve(s) who meets other coverage criteria; per four tests (does not require face-to-face service).” For the initial demonstration or provision of test materials, see codes G0248 and G0249. To familiarize yourself with the Medicare regulations for billing home INR-related services, see

E/M + trigger point injections


Can I bill an E/M code with a trigger point injection? Do I need modifier -25 and a separate diagnosis code? Can I bill the Kenalog as well?


You can bill an E/M code with a trigger point injection if the E/M service is significant and separately identifiable from the normal pre-service work associated with the injections. This would require modifier -25 but not necessarily a different diagnosis code. The Kenalog would be billed with HCPCS code J3301 (for both Kenalog-10 and Kenalog-40).

Swing bed stays


What are the rules for coding swing bed stays after acute care stays in the hospital?


Swing bed stays are generally nursing facility services. From a CPT perspective, nursing facility admission codes (99304–99306) include all services on the date of admission except hospital discharge or observation discharge services (99238, 99239, 99217 or 99234–99236). Codes 99307–99310 are used to report subsequent nursing facility care. Note that Medicare allows the billing of inpatient discharge and nursing facility admission on the same date but does not allow inpatient discharge and new inpatient admission on the same date.

When to use 99361


Can you explain the requirements for billing 99361, “Medical conference by a physician with interdisciplinary team of health professionals or representatives of community agencies to coordinate activities of patient care (patient not present)”?


This code is for case management services that require the physician to be responsible for direct care of the patient. It also requires that the physician coordinate or supervise other health care services needed by the patient. For example, some Medicaid carriers accept this code for face-to-face case conferences between a physician and health professionals or community agency representatives to coordinate care for children who have been sexually abused. Medicare and other payers that do not accept this code may accept care plan oversight codes for these types of services.

About the Author

Cindy Hughes is the coding and compliance specialist for the AAFP and is a contributing editor to Family Practice Management. Author disclosure: Nothing to disclose. 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; Emily Hill, PA-C; Joy Newby, LPN, CPC; P. Lynn Sallings, CPC; and Susan Welsh, CPC.

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 © 2006 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact for copyright questions and/or permission requests.

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