Fam Pract Manag. 2019 May-June;26(3):31.

Author disclosure: no relevant financial affiliations disclosed.



If a physician sees a patient and instructs him or her to return later that day for a blood pressure check, should our practice bill CPT code 99211 with modifier 25, “Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service,” in addition to the code for the first encounter?


No. You should charge one E/M code for the combined services. Payers typically follow guidance from the Centers for Medicare & Medicaid Services that says two separate office E/M codes may be reported on the same date only when the patient presents for two unrelated problems.



Does Medicare require using a modifier to show that an advanced practice provider such as a nurse practitioner or physician assistant provided an office E/M service incident-to a physician's services and billed under the physician's provider identification number?


No. But some health plans require modifier SA, “nurse practitioner rendering service in collaboration with a physician,” for services rendered incident-to or as a shared visit (e.g., the physician and advanced practice professional each provide significant portions of an E/M service). Though HCPCS specifies “nurse practitioner” in the descriptor, modifier SA may also be used when billing for services provided by physician assistants, clinical nurse specialists, or other advanced practice professionals specified in a payer's policy.



If a resident does an inpatient history and physical examination (H&P) and discusses it over the phone with an attending physician on one calendar day (e.g., 10 p.m. Thursday), and the attending doesn't round on that patient until the next calendar day (e.g., 10 a.m. Friday), can the attending use the resident's documented H&P to support billing for initial hospital care? Or must the resident see the patient again with the physician present and redocument the H&P?


The teaching physician may reference the resident's note but must also document that he or she personally saw and participated in management of the patient. If after seeing the patient the teaching physician agrees with the resident's documentation and the patient's condition has not changed, the teaching physician may reference that documentation in lieu of redocumenting. Any changes in the patient's condition and clinical course must be documented by the teaching physician. The teaching physician's date of service is the date he or she saw the patient.

The Medicare Claims Processing Manual specifically addresses what documentation is needed when a resident performs initial hospital care late at night and the teaching physician does not see the patient until later, including the next calendar day (see Chapter 12, §100.1.1).



I performed a biopsy of a lesion on the external ear. Should I report a code from the integumentary section or the auditory system section of CPT?


Use code 69100, “Biopsy external ear,” from the auditory system section. CPT provides this instruction at the end of the prefatory instructions for the biopsy codes in the integumentary section.



Is it appropriate to report two codes for X-rays when one is taken prior to the removal of a foreign body and the other is taken to confirm that all of the foreign body was removed?


Yes. If the two X-rays are for the same procedure (e.g., same anatomic locations or views), report modifier 76, “Repeat procedure or service by same physician or other qualified health care professional,” with the code for the second X-ray. If the second X-ray is a different procedure (e.g., fewer views), you should instead report modifier 59, “Distinct procedural service.” In either case, be ready to provide documentation if the payer requests it, including the images and a report of findings that describes indications for and any limitation of the exam, details of images reviewed (e.g., lateral or posterior), any comparisons, clinical questions answered, and impressions.


Cindy Hughes is an independent consulting editor based in El Dorado, Kan., and a contributing editor to FPM.

Author disclosure: no relevant financial affiliations disclosed.


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 © 2019 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.

Want to use this article elsewhere? Get Permissions


Nov-Dec 2020

Access the latest issue
of FPM journal

Read the Issue

FPM E-Newsletter

Sign up to receive FPM's free, weekly e-newsletter, "Quick Tips & Insights."

Sign Up Now


Tobacco Cessation Telehealth Guide

Smoking cessation counseling and pharmacotherapy options are cost-effective ways to help patients quit smoking. Learn the role telehealth can play in your practice’s efforts, along with billing, coding, and documentation tips.

Understanding and Improving Risk Adjustment in Team-Based Care

Understand the basics of risk adjustment and how it is used in value-based payment (VBP) arrangements. Learn strategies to thrive in VBP and risk-adjustment models to optimize payment while providing high-quality patient care.

Incorporating Alcohol Screening and Brief Intervention Into Practice

Incorporating alcohol screening and brief intervention benefits your patients and family medicine practice. Follow these steps to reduce risky alcohol use by choosing a screening test, establishing a practice workflow, and appropriately coding and billing.