Primary Care Coding Alert

Question: An established patient presented with mid-abdominal pain. He told the FP it had been going on for 12 hours with one episode of vomiting, but without diarrhea, fever or dysuria. The FP examined the patient and took an x-ray and a urinalysis. Are those part of the E/M code, or can we bill separately? Arkansas Subscriber Answer: You can always bill pathology and radiology codes separately from the office visit. The exam portion of the E/M visit does not include diagnostic testing.

The most appropriate office visit code in your case is most likely 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) or 99214, depending on the level of history, exam and medical decision-making. Link 789.07 (Abdominal pain, generalized) to the E/M code. Report 74000 (Radiologic examination, abdomen; single anteropos-terior view) for the x-ray, and the appropriate urinalysis code (e.g., 81000, Urinalysis, by dipstick or tablet reagent ...) for the urinalysis. Answers to Reader Questions and You Be the Coder provided by P. Lynn Sallings, CPC, compliance officer for Family Medical Center, Area Health Education Center-Northwest in Fayetteville, Ark.; and Kent Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians in Leawood, Kan.