Internal Medicine Coding Alert

Question: A patient saw the internist to get results on labs and monitoring. The physician didn't review any systems or perform a physical exam, but discussed the results and reviewed treatment options. Should I report this visit with preventive-medicine counseling code 99401?


Vermont Subscriber

Answer: If the patient has an established illness, you shouldn't report 99401 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]; approximately 15 minutes).

Instead, you should check the documentation to see if your internist spent more than 50 percent of the visit providing counseling and/or coordination of care. If so, you should choose the appropriate established patient code (99212-99215) based on the time the counseling and/or coordination of care took. Make sure that the physician documented the time and what he discussed with the patient.
 
Also, you should remember two important Medicare criteria for billing counseling and/or coordination of care:

Select the E/M code based on the total time of the face-to-face encounter, not just the counseling time. Face-to-face time means the time the physician spent with the patient. You cannot count counseling by other staff.

For example, the internist documents that the chief complaint was the patient returning to discuss treatment options and to get test results. The physician also notes that he spent 15 minutes with the patient, and more than 50 percent of that time was spent counseling and providing coordination of care. You could report 99213 (Office or other outpatient visit ...established patient ...15 minutes face-to-face with the patient and/or family).