Ob-Gyn Coding Alert

Tip: Don’t use 99401-99404 if the patient is ill.

Suppose your ob-gyn performs a problem-based E/M visit and also provides some preventive medicine counseling on an unrelated issue. If you’re not adding 99401-99404 to your claim, you could be leaving money on the table.  

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

1. What Are the 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 four 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.

Watch Out: 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.

2. How Should You Report Only 15 Minutes Counseling?

Scenario: If the ob-gyn spends 15 minutes discussing and prescribing birth-control pills during a preventive medicine counseling session with an adolescent patient, how should you report this?

Answer: Report 99401 and link it to V25.01 (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).

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. 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 in detail?

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 prescribed a certain contraceptive.

3. Can You Report a Counseling Code With a Vaccine?

Scenario: 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 other viral diseases) or V05.8 (Need for other prophylactic vaccination and inoculation other specified disease), depending on payer preferences.

Remember: If you administer the vaccine during the same visit as the counseling, -you should add modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the 99401-99404 code.

4. Can You Report Counseling, E/M on Same Day?

Scenario: Your ob-gyn sees a patient for urinary incontinence (788.3x) and then 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 the counseling was of a general nature or 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 it meets the CPT® criteria for intermediate or intensive smoking cessation counseling. The Medicare equivalent codes would be G0436 and G0437. 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, experts say.

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 non-covered service.