Fam Pract Manag. 2010 Nov-Dec;17(6):33.

Anticoagulation management


If a patient comes to my office, has an INR drawn and reviewed by a provider, and sees a nurse for instructions, can we bill a 99211?


First, this depends on whether the nurse is working incident to a physician or a qualified non-physician practitioner such as a physician assistant. If so, the service should qualify as a 99211-level service as long as the documentation includes the signatures of both the nurse and the supervising physician, identifies the physician's name and credentials, and conveys the following key facts:

  • That the service is a continuation of the physician's management of the patient (e.g., by referring to a prior evaluation and management visit with the physician),

  • That the service is medically necessary (e.g., by referring to pertinent information such as hospitalizations, emergency department visits, new co-morbid conditions, medication changes, bleeding, bruising or dietary changes),

  • That management took place during the face-to-face encounter (e.g., by noting that lab results were provided to the physician, who reviewed both the test result and evaluation and provided instructions),

  • That the nurse relayed the physician's instructions to the patient and addressed the patient's questions.

Be careful about using templates that oversimplify these requirements and do not address ongoing physician supervision, patient evaluation and management.

Site of service for initial hospital care


Is it acceptable to submit a hospital admission code for evaluating a patient in the office and then directly admitting him or her to the hospital on the same day?


It is not acceptable to submit a charge for initial hospital care before you provide the first care to the patient in the hospital setting. CPT defines initial hospital care as the first hospital inpatient encounter with the patient by the attending physician and further states that this service includes all related evaluation and management services provided on that same date in other settings, including the office. If you see the patient in the office, order admission and then later on the same date provide a face-to-face service to the patient as an inpatient, you may combine your work to arrive at the appropriate initial hospital care code (99221–99223). If you do not see the patient in the hospital until the next calendar day, your initial hospital care takes place and is reported on that date, and the office encounter that occurred the day before may be reported as well.

Billing separate services for OB patients


When treating a pregnant patient for allergies and asthma unrelated to her pregnancy, can I bill separately for the allergy and asthma 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 up to 36 weeks gestation, and weekly visits until delivery. Any other visits or services within this time period should be coded separately.”

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, 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.


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 © 2010 by the American Academy of Family Physicians.
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