The Coding Primer
“How to Code” basics for primary
Updated for 2009
Coding: “Can’t Live With It. Can’t
Live Without It.”
• Coding is important because it builds the
electronic health record.
• It is the language we use to collect our
• It has become and will become even more
the means by which we will be alotted
cash and manpower.
How are we doing now?
• 573 encounters audited by our coders in
• 84.05% Diagnosis correct.
• 74.57 % Eval/management codes correct.
• 67.18 % CPT codes correct. Document
what you performed. Method / Location /
Quantity / Size / Layers / Time frames.
• 51 % of encounters had errors found!
• Code only what you know. If the diagnosis is “likely” or
rule-out code for the symptoms the patient is having.
E.g. CHF rule out can be coded as lower leg swelling.
• Don’t code for resolved conditions. Instead use the
v67 series for follow up exams.
• List complicating factors. Comorbidities, other chronic
conditions the patient may have, adverse effects of
medications that may be indicated. Helps to determine
the complexity of the decision making process you are
• Try to be clear about taking intermediate
steps to address a patient’s condition.
This can boost the complexity of the
condition to the coder. Trying first physical
therapy, nsaids prior to surgical
consideration for example.
• Use the “50%” button as the exception,
not the rule.
• Be specific about reviews of labs or
xrays. Labs reviewed with patient showed
elevated wbc indicating sepsis or
inflammation. If a patient is following up
blood pressure check tell what was wrong
with the blood pressure to begin with.
• Be sure to add the nurse, MA or corpstaff
as an additional provider to help show
• Medical necessity should drive ordering of
labs or other diagnostic studies. Write a
story that tells why these labs need to be
done. The complexity of the office visit is
based on the story not on the fact that so
many labs were ordered.
• When applicable, code “obesity” as it
can help to increase the medical decision
• Collect credit for diagnostic decisions.
If the provider went through the medical
decision making process to determine a
patient needed a certain test, even though
the patient refused the test, the provider
should receive credit for that process,
provided the process is documented. E.g.
colonoscopy screening / tobacco
cessation counseling / obesity nutrition
• For residents…Give name of staff you
discussed the case with.
• Vital signs must be stated to have been
• EKG must be reviewed in your note to
obtain credit for having done it (CPT
• LOOK! At your clinic favorites for CPT
codes and for Diagnoses!
Code for the -25 modifier.
• When a procedure is done separate from
the office visit diagnosis. When providing
a specific treatment plan during a prev
med visit. E.g. during a PAP smear patient
brings up depression and you counsel and
provide medical therapy. During an EST
patient elects to start tobacco cessation
and you perform counseling.
How to: Code for Preventive Med Visits
• V20.2 visit for: Well baby, Well
• V72.31 Normal Pelvic Exam
with Cervical PAP (Well
• V76.2 Screening Pap
• V70.0 Normal Routine History
and Physical (Well Adult)
• V70.3 School/Camp Physical
• Disposition: Age-Appropriate
Prev Med Code! E.g. 99395
RVU = 1.36 (99213RVU =
How to: Code for Routine OB Care
• V22.0 Supervision of Normal
• V22.1 Supervision of
• V22.2 Pregnancy incidental to
• CPT ! : NOB = 0500f,
Antepartum = 0502f, Post-
Partum Exam = 0503f
• Disposition : 99499
99499 with 0500.0502,0503 =
0.83 rvu !
How to: Code for Well Woman Visit
• V72.31 Routine Physical Exam with a
GYN component. When cervical PAP
Smear is performed must add
diagnosis V76.2 Screening PAP.
• If s/p hysterectomy V72.31 still applies
with V76.47 for vaginal PAP.
• CPT/HCPCS!: “Q0091” Obtain PAP /
Transport to Lab
• 87210 wet prep/koh (done and
interpreted in clinic) 82272 Hemoccult
from DRE (done in clinic).
• Q0091 RVU = 0.37
• Disposition: Use age-appropriate
Prev Med Code!
How to: Code Tobacco Cessation
• 305.1 Nicotine Dependence
• New! CPT: in E&M section
add “Additional E&M” code
using -25 modifier.
• 99406: 3-10 minutes of cessation
• 99407: > 10 minutes of cessation
• 96153: provider group visit
• HCPCS S9453: non-provider
• 99406 RVU = 0.24
• 99407 RVU = 0.50
How to: Code Obesity
• V77.8 visit for:
How to: Code for Skin Biopsies
• Punch / Shave Biopsy of:
• Macules and Papules 709.8
• Subcutaneous Nodule 782.2
• Acrochordon 701.9
• CPT Biopsy Skin:11100
• Each additional biopsy: 11101
• CPT Skin tag removal: 11200
(up to 15 lesions)
• Each additional 10 biopsies:
• CPT Destruction of benign
lesion by cryotherapy: 17110: up
to 14 lesions 17111: 15 or more
How To: Code for Exercise Stress Testing
• Exercise Stress Test:
786.50 Chest pain or
v81codes visit for:
(no hx recent chest pain)
• CPT Cardiovascular
Stress Test: 93015
• CPT Stress Test with
How To: Code for Colposcopy
• Colposcopy Diagnosis:
795. series Abnl PAP of
• CPT Colposcopy without
• CPT Colposcopy with
biopsy of cervix and ECC
• CPT Colposcopy with
ECC only 57456
• CPT Colposcopy with
biopsy only 57455
How To: Code for Vasectomy
• Pre Vasectomy
• Vasectomy Procedure:
v25.2 Surgery of Male
• CPT 55250
How To: Code Chronic Kidney Disease
• 585.9 Chronic Kidney
• 403.9 Hypertensive
How To: Code Adverse Drug Reaction
• E947.9 Adverse
Effect of Drug
• Enter Medication as
“ADR” / list effect drug
had on patient.
How To: Code for Diabetes
• Diabetes 250.00
• Pre-Diabetes (Impaired
• Gestational Diabetes
• Visit for: Screening Exam
• CPT: for Foot Exam
• 2028F: for normal exam
G0247: if neuropathy is
How To: Code for Alcohol Use Counseling
• 305.00 Alcohol
• 303.90 Alcoholism,
How To: Code for Mammogram Review /
• CPT: Review
How To: Code for Osteoporosis Screening
• Osteoporosis 733.00
• Visit for : screening
How To: Code for Colon Cancer Screening
• Visit for: Screening
• Heme Occult testing
CPT: 82272 if
performed in the clinic
• Flex Sig CPT: 45330
How to: Code for Screening Exams
• V76.51 screening colon
• V77.1 screening,
• V76.9 screening cancer,
• V77.91 screening lipid
• V81.0 screening cardiac
• V82.9 screening,