Medicare Compliance & Reimbursement

You could be missing out if you don't report preventive medicine counseling codes 99401-99404 on the same day as a problem-based E/M visit when your physician counsels the patient on an unrelated issue.

Crux of the problem: "Sometimes a patient comes in for preventive care/counseling without a specific problem or complaint, and we're hesitant to code these visits correctly because we're worried about the insurance company not paying for the service," says Karen Green, CPC-H, OGS, coding specialist for Eau Claire Women's Care in Wisconsin. "But what we have to remember is that we have to code correctly for the service, not code to be paid."

Situation 1: The physician spends 15 minutes discussing and prescribing birth-control pills during a preventive medicine counseling session with an adolescent patient. How should you report this?

Situation 2: An established patient presents to your physician and wants counseling as to whether she should have the HPV vaccine. Once she learns about its benefits, she wants to have the vaccine on the same day.

You should report 99401 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]; approximately 15 minutes) and link it to V25.01 (Encounter for contraceptive management; prescription of oral contraceptives).

When the physician prescribes alternatives such as the contraceptive patch during a preventive medicine counseling session, link V25.02 (Initiation of other contraceptive measures) to the appropriate code for preventive medicine, individual counseling (99401-99404). Keep in mind, however, that V25.02 excludes intrauterine devices (IUDs).

Remember: Because 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, says Cindy Foley, billing manager for three practices in Syracuse, NY.

Note: If an adolescent comes in for a follow-up visit after an initial birth-control prescription, you can report a regular E/M service (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) with a birth-control diagnosis (V25.4x).

Reason: The physician is now monitoring the side effects of the drug. Most of these visits will involve counseling.

To make sure your documentation has what it takes, you should go through this checklist:

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 time counseling or coordinating care?

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

For this situation, you should report the following:

• one of the 99401-99404 codes

• 90649 (Human papillomavirus [HPV] vaccine, types 6, 11, 16, 18 [quadrivalent], 3-dose schedule, for intramuscular use) for the vaccine

• 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid]) for the injection.

 Keep in mind: You should link 99401-99404 with diagnosis code V65.45 (Counseling on other sexually transmitted diseases).

Also, you should link 90649 and 90471 with a diagnosis of either V04.89 (Need for prophylactic vaccination and inoculation against certain viral diseases; other viral diseases) or V05.8 (Need for other prophylactic vaccination and inoculation against single diseases; other specified disease), depending on payer preferences.

If the patient sees the physician just for counseling and does not have an established illness, you should use one of four codes, says Green. Depending on the session's duration, assign:

• 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 diagnostic and laboratory test results available at the time of the encounter.

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. For example, use a 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 patient.