EM Coding Alert

Know the ins and outs of reporting 99401-99404.

Do you know how to apply 99401-99404, the preventive medicine counseling codes, correctly? Even if you answer “yes” to this question, you’ll find a lot of useful information in these two scenarios that will help you capture the counseling your ob-gyn performs for your patients when they report without an established illness.

Study Preventive Medicine Counseling Codes

If the patient sees an ob-gyn just for counseling and does not have an established illness, you should use one of three codes, depending on the counseling session’s duration:

• 99401 (Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes)
• 99402 (... approximately 30 minutes)
• 99403 (... approximately 45 minutes)
• 99404 (... approximately 60 minutes).

According to CPT^®, counseling codes apply when a physician counsels on family problems, diet and exercise, substance abuse, sexual practices, injury prevention, dental health, and normal diagnostic and laboratory test results available at the time of the encounter.

Caution: In other words, the purpose of the visit must be promoting health and/or preventing illness or injury. If the patient is ill, you shouldn’t use the preventive counseling codes. “CPT^® clearly states that you should not use these codes when counseling patients with symptoms or an established illness,” says Peggy Stilley, CPC, CPC-I, CPMA, CPB, COGBC, revenue integrity auditor in Norman, Oklahoma.

For example, use a preventive counseling code when the doctor provides counseling on diet and exercise for a well patient who wants to lose weight, but not when the doctor provides the same services to a diabetic.

Example 1: Master This Birth-Control Scenario

If the ob-gyn spends 15 minutes discussing and prescribing birth control pills during a preventive medicine counseling session with an adolescent patient, report 99401 and link it to Z30.011 (Encounter for initial prescription of contraceptive pills).

When the physician prescribes alternatives such as the diaphragm during a preventive medicine counseling session, link Z30.018 (Encounter for initial prescription of other contraceptives) to the appropriate code for preventive medicine, individual counseling (99401-99404). You should note, however, that Z30.018 excludes intrauterine devices (IUDs), vaginal ring prescription, subdermal implants and the contraceptive patch. Each of these methods now have their own diagnostic codes.

Remember: Because codes 99401-99404 are time-based, your physician must document the amount of face-to-face time spent counseling, and the content of the counseling is crucial. Notes for the counseling visit should include references to pamphlets or other materials the physician reviewed with the patient.

Keep in mind: If the patient comes in for a follow-up visit after an initial birth-control prescription, you can report a regular E/M service (99212-99215) with a birth-control diagnosis (Z30.40-Z30.49) because the physician is now monitoring the side effects of the drug, coding experts say. And because most of these visits will involve counseling, you should go through this checklist to make sure your documentation has what it takes:

1. Does the documentation reveal the total face-to-face time in the outpatient setting?
2. Does the documentation describe the content of the counseling or coordination of care?
3. Does the documentation reveal that the physician spent more than half of the face-to-face time counseling or coordinating care?

If all of the answers are “Yes,” you should select the office visit E/M service level service based on the total encounter time (in minutes) but be aware that some insurance carriers ask for specific documentation that shows the time the counseling began and ended.

Best bet: You’ll stand a better chance of convincing payers to reimburse for counseling if you’re able to provide particulars on the content of the discussion and reasons the physician prescribed a certain contraceptive.

Example 2: Sort Out Counseling, E/M on Same Day

Your ob-gyn sees a patient for urinary incontinence, which you would report with the appropriate diagnosis code.

Then, your ob-gyn spends time counseling the patient on smoking cessation. In this case, you could report the 99401-99404 codes in addition to the problem E/M code, such as 99214 (Office or other outpatient visit for the evaluation and management of an established patient ...) if this was general counseling regarding the benefits of quitting. Alternatively, you would report codes 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes) or 99407 (Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes) if the ob-gyn performed counseling as part of the treatment of condition(s) related to or made worse by the smoking.

In general, this type of counseling requires use of specific validated interventions of assessing readiness for change and barriers to change, advising a change in behavior, assisting by providing specific suggested actions and motivational counseling, and arranging for services and follow-up. You should add modifier 25 to the problem E/M code.

Key: The urinary incontinence is not related to the smoking cessation. If the patient presents to the office for a problem visit and the doctor counsels the patient on a different issue, you can report both.

Look out: You should not increase the E/M service level because of the preventive counseling. The reason is that your ob-gyn is not spending the time on the problem (urinary incontinence) but is providing preventive counseling on smoking. This will be particularly important for those payers that do not cover preventive care, because this means you would be hiding the fact that the ob-gyn provided a noncovered service.