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Coding for a rectal exam at an office visit; billing nutrition services; coding for 2 visits in 1 day


Understand the rules for coding a rectal exam performed at an office visit when billed with an E/M code.

A: Your question did not indicate which specific method was used for the rectal exam of the patient, so I will presume it was a digital exam. A digital rectal exam is considered part of the E/M service. If a scope was used, then coding for the service would depend on the type of scope. An anoscope used to perform a surgical anoscopy, which always is preceded by a digital examination, is reported with the code 46600. The 46600 series of codes also is used to report dilation, biopsy, removal of foreign object, or removal of a lesion or tumor by snare method. This coding series is not used for the treatment of hemorrhoids, however. Reporting hemorrhoid treatment depends on the location of the hemorrhoid (internal/external) and the method used for treatment. Any service on the same date as an E/M service probably will require that the modifier 25 be added to the level of service chosen.


A: Your example indicates that the patients being seen by the nutritionist have established diagnoses. I presume that the visits with the nutritionist are for the purpose of evaluating dietary adherence and reinforcing behavior with re-assessment and education. Medical nutrition therapy, 97802–97804, should be reported depending on the service provided; 97802 is the initial assessment and intervention with the patient (each 15 minutes), 97803 is the re-assessment and intervention, individual (each 15 minutes), and 97804 is to report group sessions (2 or more individuals) (each 30 minutes).

Counseling and risk factor reduction performed by a physician or other qualified professional are reported with codes 99401–99412 for patients without established diagnoses. In addition, health and behavior assessment/intervention codes (96150–96155) are used to identify psychological, behavioral, emotional, cognitive, and social factors in patients with established diagnoses. Although this evaluation has a psychological component, it should not be confused with psychiatric services codes (90801–90899).

If the services of the nutritionist are being reported as "incident to" (billed with the provider number of a physician), then the incident-to rules for any insurer billed must be met. That means that if there are group sessions in the evenings, one of the physicians may have to be on site to supervise the activities of the nutritionist. Those services should be billed with the provider number of the supervising physician if Medicare incident-to rules are used by the insurer.


Q: I am a hospitalist in a group of 15 physicians. Those working the overnight shift, from 7 p.m. to 7 a.m., see all patients on rounds but only bill for those they see before midnight. Are there circumstances that allow the day-shift doctors to bill for re-evaluation services provided to patients who were admitted after midnight and originally seen during the overnight shift? In such cases, can a day-shift physician bill for a subsequent visit occurring on the same day?

A: Your example seems to involve follow-up on tests ordered, with appropriate action based on the results of those tests. Two providers of the same specialty, from the same tax ID group, cannot render the same service to the same patient on the same date. All services rendered to a patient within a 24-hour period (based on the date of service) should be combined and billed at the appropriate level of care by 1 provider. That being said, circumstances could exist wherein a patient is admitted and later the same day develops a complication or additional problem that must be treated immediately. You could charge for a second visit, but documentation would need to show the necessity of that visit. Not all insurers will pay for a second visit, even with documentation, however.

Medical Economics consultant Virginia Martin, CPC, CHBC, is president of Healthcare Consulting Associates of NW Ohio, Inc. She has more than 30 years of experience as a practice management consultant and also is a certified coding specialist, certified compliance officer, and certified medical assistant. Do you have a primary care-related coding question for our experts? Send it to

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Jennifer N. Lee, MD, FAAFP
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