Fam Pract Manag. 2007 Nov-Dec;14(10):15-16.

Same code for same procedure


I am planning to perform several procedures in my new family medicine office. Is there a difference between the codes and modifiers I should report for a procedure and those other specialists report for the same procedure? Will my reimbursement be the same as theirs?


All physicians report the same code for the same procedure. CPT codes are not specialty specific; they describe the typical physician work involved in providing a specific service. Modifiers do not vary between specialties either. They provide payers with additional information about procedures and services that may affect payment.

Your payment for a procedure will depend on the payer. Payers other than Medicare may offer specialty-specific fee schedules or conversion factors, a practice the AAFP opposes. (For more information on the AAFP's policy on physician payment, visit

Initial hospital care and 99221


How should we bill for initial hospital care when the documentation does not meet the requirements for even the lowest level code, 99221?


First you need to determine whether the documentation was incomplete or whether it was simply not medically necessary to perform the three key components required for coding 99221. If the documentation was incomplete, it may be appropriate to dictate an addendum to the record before reporting the service. This will notify the payer of the services you performed and support your case for a 99221. If the components of a 99221 were not medically necessary because a comprehensive history and exam were performed within days of the initial hospital care, consider reporting the unlisted evaluation and management (E/M) service code 99499 with accompanying documentation of the level of service provided.

Prothrombin time testing with 99211


I am considering adding CLIA-waived fingerstick prothrombin time testing to my outpatient clinic services. In addition to charging for the fingerstick (36416) and the test (85610), can I also bill a level-I office visit to cover my nurse's involvement in obtaining the specimen, running the test, processing the results and adjusting the warfarin dose?


It depends. If your nurse provides a medically necessary E/M service to the patient and if your payer has a policy that allows the reporting of E/M services by nurses under the supervision of a physician (e.g., Medicare's incident-to billing rule), you may report a 99211 in addition to 36416 and 85610. Check with your private payers to determine whether they have an incident-to rule in place.

Reports from Medicare audit contractors have noted that the documentation for these types of visits often fails to indicate medically necessary E/M services, which has led to the denial of 99211 services. To meet the requirements for a 99211 visit, nurses should document the reason for the visit, changes in the patient's history, medications or diet, instructions for continuing the physician's plan of treatment, and any discussion that occurs. For more guidance, see “Understanding When to Use 99211,” FPM, June 2004, and “The Ins and Outs of ‘Incident-To’ Reimbursement,” FPM, November/December 2001.

You should also check which payers reimburse anticoagulation management under codes 99363 (for the first 90 days of therapy) and 99364 (for each subsequent 90 days of therapy). These codes include the physician review and interpretation of test results, patient instructions, dosage adjustment (as needed) and ordering of additional tests. When reporting 99363 and 99364, you may not report an E/M office visit code. (Note that Medicare does not reimburse the anticoagulation management codes in 2007, and the proposed rule for 2008 still lists them as noncovered.)

Trigger point injections


Trigger point injections (20552 and 20553) are reported frequently as surgery on our patients' explanation of benefits (EOB) forms. Some patients believe we are falsely trying to bill for surgery when they only had an injection done. Can we change the way the insurance companies describe these injections on the EOBs?


The terms that appear on EOBs are often related to the plan provisions under which the benefits are paid. These are not easily changed. It may be more beneficial to educate your patients as to the CPT classification of services. This statement could be included in a payment policy you provide to patients at an initial encounter: “Medical services are subject to classification by physicians and health insurers. Invasive procedures such as injections to joints are often classified as surgery, even though there is no incision. Should you receive a billing or insurance notice that is unclear, please feel free to contact our billing staff with any questions.”

Removing multiple lesions


If we remove three benign skin lesions of the same size, should we bill the CPT code with three units on one claim line, or must we report the CPT code three times and append a modifier for multiple surgery procedures?


If all three removals are reported on one claim line, the payer has no indication that the lesions were distinct, which will delay your payment. Instead, report multiple claim lines with modifier -51 for multiple procedures and modifier -59 for distinct procedural services both appended to the CPT codes for the two additional lesions removed. I recommend putting modifier -59 first (e.g., 11310-59-51) because it is the modifier that bypasses coding edits, and payer systems sometimes fail to pick up multiple modifiers. Coding edits established by private payers may vary, so check your payer policies for multiple procedures prior to claim submission.

90805 includes E/M services


Can I report office visit code 99213 with modifier -25 and code 90805 for psychotherapy at the same visit?


No. Code 90805 reports that psychotherapy and medical E/M services were provided on the same date, which includes evaluation and management of comorbid conditions, drug interactions and physical examination.

Using test results as a diagnosis


Is it correct to use the diagnosis that results from a radiology test to support the CPT code for the visit at which the test was ordered?


The ICD-9 guidelines state that for outpatient encounters involving diagnostic tests that have been interpreted by a physician, you can code any confirmed or definitive diagnosis(es) documented in the interpretation. However, this may not be the most practical approach since it requires that you wait to submit your claim until the results are available. Basing your code on the signs and symptoms that prompted you to order the test would also be correct and would allow you to submit the claim without delay. You would also need to code the signs and symptoms that prompted you to order the test if you held the claim but the test results turned out to be normal or inconclusive.

NPs and care plan oversight


Can a physician use incident-to billing when a certified nurse practitioner performs 30 minutes of care plan oversight (CPO)?


No. However, Medicare carriers will allow nonphysician practitioners to bill under their own number for home health CPO even though they cannot certify a patient for home health services or sign the plan of care.

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.


About the Author

Cindy Hughes is the AAFP's coding and compliance specialist and is a contributing editor to Family Practice Management. Author disclosure: nothing to disclose. These answers were reviewed by the FPM Coding & Documentation Review Panel: 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; Terry L. Mills Jr., MD; Kent J. Moore; Joy Newby, LPN, CPC; P. Lynn Sallings, CPC; and Susan Welsh, CPC, MHA.


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 © 2007 by the American Academy of Family Physicians.
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