Fam Pract Manag. 2008 Feb;15(2):40.

Selecting the primary diagnosis


If a patient comes in for a scheduled appointment to address his chronic conditions, but he also has a new condition that I evaluate, which diagnosis is considered the primary one?


The ICD-9 coding guidelines instruct you to “List first the ICD-9-CM code for the diagnosis, condition, problem, or other reason for the encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions.” Based on this, consider to what extent the new problem and chronic problems were the reason for the services provided. The primary diagnosis is the one that accounted for the greatest portion of your care.

INR testing at a nursing home


Our practice has been taking our CLIA-waived INR instrument to the nursing home and managing warfarin dosage at the bedside. We billed the initial encounters as nursing home visits and INR testing, but Medicare would not pay because we did not have a CLIA number that matched the place of service (the nursing home). Would it be appropriate to bill using our office as the place of service for the lab work and the nursing home as the place of service for the management work?


No, it would not be appropriate to report a place of service code that doesn't match the setting where the service was truly provided. Because your CLIA certificate is specific to your office lab, changes in your certification may be required to enable you to do testing elsewhere. Also, Medicare pays skilled nursing facilities under a consolidated billing program that includes the technical costs of lab testing. This may require that either the nursing facility provide the tests or that you contract with the facility to do so. I would suggest consulting a health care attorney before continuing to provide this service.

Pregnancy test at a preventive visit


Can I be paid for a pregnancy test provided on the same date as a preventive service visit? If so, what code should I submit?


A pregnancy test performed on the same date as a preventive service may be reported separately using the CPT code appropriate to the test (e.g., 81025, “Urine pregnancy test, by visual color comparison methods”) and a diagnosis code from the V72.4X series (pregnancy examination or test). Note that many payers state that if the initial prenatal care is begun at the same encounter where pregnancy is confirmed, the visit is included in the global OB package and not separately billable.

99211 + injection code?


Our nurse and medical assistant often provide various injections, such as B-12 or allergy shots. We always take vital signs and document how the patient is feeling and whether there are any problems. Why can't we bill a 99211-25 along with injection code 90772 for these visits?


Code 99211 represents an evaluation and management service where problems are typically minimal and may not require the presence of a physician. The addition of modifier 25 suggests that the service is significant and separately identifiable from the other services. Medicare and many other payers bundle 99211 with 90772.

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, 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; Kent J. Moore; Joy Newby, LPN, CPC; P. Lynn Sallings, CPC; and Susan Welsh, CPC, MHA.

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 © 2008 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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