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A patient who's new to the practice but not to the doctor, Assigning codes based on symptoms or findings, Which code to use for a face lesion biopsy


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A patient who's new to the practice but not the doctor

Q: I saw a patient I'd seen two years ago at a different practice. Should I bill this encounter as a new patient visit or as an established patient visit?

A: You shouldn't bill this as a new patient visit. According to CPT E&M services guidelines, a new patient is an individual "who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years." Using this definition, the patient has indeed received services from you within the previous three years (albeit at a different practice) and should be considered an established patient.

Assigning codes based on symptoms or findings

Q: Should we assign a diagnosis code based on the symptoms that a patient presented with, or based on what the physician determined is the cause of the symptoms? For instance, if a child comes in with fever and I conclude the fever is caused by an ear infection, which code would I assign?

A: It depends. For an office visit, practices traditionally assign a diagnosis code reflecting the findings. However, if the physician orders further tests to determine the cause, the signs and symptoms are used most often to determine the coding. For example, report ICD-9-CM code 382.9 (unspecified otitis media) with the E&M service provided to the child above rather than the code for high fever (780.6). If an elderly man presents with shortness of breath, and an X-ray determines the cause to be pneumonia, report 786.05 (shortness of breath) as the primary reason for the study.

Increasing numbers of local Medicare carriers and private payers are accepting findings—in the case of the X-ray above, 485 (bronchopneumonia, organism unspecified)—as the reason for further tests. The idea behind this change is that patient encounters should be coded to the highest degree of specificity possible. Because payer policies vary greatly, coders should determine local requirements and assign the ICD-9-CM codes that comply with guidelines.

Which code to use for a face lesion biopsy

Q: If I remove a lesion from the face for biopsy and send it for pathology review, should I bill both 11440 and 11100?

A: The distinguishing factor here is whether you remove some or all of the lesion. If you take only a piece of the lesion for biopsy, use 11100 (biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed [separate procedure]; single lesion). The code is for the procedure itself and would not be billed with 11440 (excision, other benign lesion [unless listed elsewhere], face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less). Code 11440 would be used if you completely remove the lesion and then send it for pathology.


This information provided by The Coding Institute. For a free sample issue or information on how to subscribe to any of 29 specialty-specific coding newsletters, please contact The Coding Institute, 2272 Airport Rd. South, Naples, FL 34112; phone 800-508-2582; fax 800-508-2592; or visit


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