# Preventive Services



## bmanus (May 15, 2013)

Hello Forum!

I was wondering if any can tell me if billing new or established office visits are the correct codes to be for genetic counseling. Since BRCA is covered under the preventice act I wasn't sure which code to use.

Thanks 
Beth


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## btadlock1 (May 16, 2013)

bmanus said:


> Hello Forum!
> 
> I was wondering if any can tell me if billing new or established office visits are the correct codes to be for genetic counseling. Since BRCA is covered under the preventice act I wasn't sure which code to use.
> 
> ...



It's difficult to tell, with so little information to go on - the answer will depend largely on the content of the visit. Does the patient have an identified risk factor, or an established problematic diagnosis? Or is this strictly preventive? Is it limited to genetic counseling, or could it be considered a comprehensive preventive visit?

Depending on the answer, it could range from a regular preventive exam (99381 - 99397), something from the 99401-99404 range, 99420 or even 99429. It might even fall under a regular office visit (if the patient has an established problem), which wouldn't qualify for coverage under the preventive benefit of PPACA. Could you provide more details?


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## fmuldoon (May 16, 2013)

Additional information would be nice, but may be you can figure out from what you have as office medical records to see if these codes work for you.

96040  
Medical genetics and genetic counseling services, each 30 minutes face-to-face with patient/family  

Other codes to consider are:
Education/genetic counseling by a physician or other qualified health care provider to a group (99078)

Education/genetic counseling by a physician or other qualified health care provider to an individual (99201-99499 [99224, 99225, 99226, 99485, 99486])

Education regarding genetic risks by a nonphysician to a group (98961, 98962)

Genetic counseling and/or risk factor reduction intervention from a physician or other qualified health care provider provided to patients without symptoms/diagnosis (99401-99412)

Do not report when 15 minutes or less of face-to-face time is provided.

Fran Muldoon LPN, CPC
Providence R.I. Chapter President.


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## bmanus (May 16, 2013)

Thank you very much! We have a CMS that sees patients who have personal and/or family histories of cancer. I have been billing these under 99201-99205 or 99211-99215 for those that are coming back for their results.

So if I use 96040 with V84.01 or V84.02 do you think that would qualify under the Care Act? I will check with the insurances of course.


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## bmanus (May 16, 2013)

Here is an example of one report, I chose this since the patient has a low risk would that qualify for the BRCA preventive?


Met with patient to provide breast cancer risk assessment.


Personal history:  Patient reports a history of squamous cell skin cancer.  She reports a history of polycystic ovary syndrome. She has a history of lipoma.  She denies any personal or family history of uterine fibroids, or thyroid growths or cancer. She denies any personal history of blood clots (DVT or PE) and has never taken coumadin. She is pre-menopausal. 


Family history:  See history navigator and pedigree. Patient reported more breast cancer on her questioniarre, but checked an old email from her mother during our session and found out her grandmother had cervical cancer, not breast.  Patient states her mother took tamoxifen. She reports her father was slender and did not smoke, but had multiple strokes starting about age 45.


Risk assessment for hereditary breast cancer:  In reported family history, there are no breast cancers known to be diagnosed prior to age 50, no ovarian cancer, or male breast cancer. The pattern of breast cancer in the family does not strongly suggest heredity.  


I advised patient that she is at low risk for hereditary breast cancer and is unlikely to benefit from genetic testing for hereditary breast cancer. However, her risk for breast cancer is increased due to her family history.   


Breast cancer risk: According to the Gail Model, the patient's risk of being diagnosed with breast cancer in the next 5 years is 1.8% (average is 1%).  Her risk to age 90 is 19.6% (average 11.9%).  Provided patient with her Gail Model risk information.  Since her 5-year risk is >1.67%, she meets the risk cutoff to take tamoxifen for 5 years for breast cancer prevention.  However, tamoxifen is associated with a small increase in risk of blood clots. She reports her father did not smoke and was slender.  He had multiple strokes starting at about age 45.  I discussed with the patient that the risks of tamoxifen given her father's history may outweigh the benefits in her case.  I also provided information on the Vitamin D study breast cancer prevention study.  The study compares a standard dose of Vitamin D to a larger dose with the endpoint being breast density.  Patient expressed interest in the Vitamin D study and agreed to be contacted about it, so I  ask research RN, to contact her.      


Breast cancer screening: Advised patient to continue having annual breast exam and mammogram.  Since her mother was diagnosed past age 50, patient does not meet current criteria for screening breast MRI based on her family history.   


Patient's response to information:  Patient verbalized understanding of all information presented. I provided her a copy of her Gail Model risk estimate.


Plan:  Routine follow-up with primary care provider.   

40 minutes were spent with patient. 100% of time was spent counseling.


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