Ob-Gyn Coding Alert

Warning: Avoid reporting 99401-99404 if the patient is ill.

If you’re not reporting preventive medicine counseling codes 99401-99404 on the same day as a problem-based E/M visit when your ob-gyn counsels the patient on an unrelated issue, you could be missing out on reimbursement.

Learn how to determine which code to report and what documentation you need using these three scenarios.

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 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, COBGC, ACS-OB, director of auditing services at the American Academy of Professional Coders.

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.

Scenario 1: Master This Birth-Control Example

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 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). You should note, however, that V25.02 excludes intrauterine devices (IUDs).

ICD-10: When your diagnosis coding system changes, you should report Z30.011 (Encounter for initial prescription of contraception pills) instead of V25.01. Instead of V25.02, you should report one of the following codes, depending on what kind of contraception the ob-gyn discusses:

• Z30.013 — Encounter for initial prescription of injectable contraceptive
• Z30.014 — Encounter for initial prescription of intrauterine contraceptive device
• Z30.018 — Encounter for initial prescription of other contraceptives
• Z30.019 — Encounter for initial prescription of contraceptives, unspecified

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, Farmer says. Only total time counts for these codes so indicating that greater than 50% of the face-to-face time was spent on counseling would be considered incorrect documentation. Notes for the counseling visit should include references to pamphlets or other materials the physician reviewed with the patient.

Keep in mind: 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) with a birth-control diagnosis (V25.4x) 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 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 needs to continue monitoring the prescribed contraceptive.

Scenario 2: Help Yourself by Tackling HPV Problem

An established patient presents to your ob-gyn 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. That means you should report:

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.

Note: You should link the 99401-99404 code with 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.

ICD-10: When your diagnosis coding system changes, you’ll report Z71.89 (Other specified counseling) instead of V65.45. Instead of V04.89 or V05.8, you’ll report Z23 (Encounter for immunization).

Don’t forget: If you administer the vaccine during the same visit as the counseling, you should add modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the 99401-99404 code.

Scenario 3: Sort Out Counseling, E/M on Same Day

Your ob-gyn sees a patient for urinary incontinence (788.30, Urinary incontinence, unspecified;) and then spends time counseling the patient on smoking cessation. In this case, you should 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 ...). 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. To get paid for both, you would more than likely need to submit the claim with the documentation to support both codes.

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 (788.3x) 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.