Fam Pract Manag. 2008 Mar;15(3):41.

Coding a brief service for urinalysis


When patients want to be seen due to symptoms of a urinary tract infection, we typically provide a brief service in our ancillary services area with a dipstick urinalysis and no physician encounter. Should we report only the urinalysis?


You may be able to report 99211 as well if the service was documented and involved some evaluation and management of the patient. Coding 99211 requires that a chief complaint be documented along with any other elements of the visit. For example, you should include the history of the present illness, the urinalysis results, instructions given to the patient and medications prescribed.

Preoperative testing


Sometimes patients arrive for their appointments with forms from their surgeons requesting preoperative labs, X-rays or electrocardiograms. The patients' health plans do not always cover these tests. What should we do?


If the surgeon or the hospital requires this testing and you do not believe it is medical necessary, contact the health plan to verify the patient's benefits. If the health plan won't cover the service, notify the patient and surgical office and agree to provide it only if the patient pays at the time of the visit. If you deliver the service before learning that the health plan will not pay, there is not much you can do except check your contract to see whether you can bill the patient. You cannot change the diagnosis code if there is no medical indication other than preoperative evaluation. To help prevent this problem, train your scheduler to ask callers the reason for the appointment. In some cases, this will bring the issue to the surface before the visit, which will increase your chances of handling the situation without damaging your relationship with the patient. You should also communicate with the surgeons in your area to make them aware of the problem.

Teaching patients to administer injections


How should I bill payers when I teach patients how to self-administer insulin injections?


Consider billing an evaluation and management (E/M) service based on the time spent counseling or coordinating care. Patient and family education are components of physician counseling, according to CPT. For more information, see “Time Is of the Essence: Coding on the Basis of Time for Physician Services,” FPM, June 2003.

Instruction to the patient by qualified health care staff (e.g., a medical assistant or nurse) under direct physician supervision can be reported with code 99211 when no physician service is provided on the same date.

Chronic venous stasis ulcers


How should I code dressing changes for chronic venous stasis ulcers? Does the use of an Unna boot or chemical debridement change the coding?


Dressing changes without debridement, other than an Unna boot, are included in the E/M service provided to the patient on that date and not separately billable. Chemical debridement by a physician is also included in the E/M service provided. Application of an Unna boot should be reported with code 29580.

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 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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