Ob-Gyn Coding Alert

Question: We have an in-patient addicted to meth and other drugs. The ob-gyn documented that he advised the patient to stop using drugs. Should we bill this service with 99406 or is there another appropriate code?

California Subscriber

Answer: No. You would not report 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes) for an alcohol and substance abuse screening and intervention. You should only report 99406 for smoking and tobacco-use cessation counseling.

You have a separate set of codes to choose from for alcohol and/or substance abuse:

• 99408 (Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes)
• 99409 (… greater than 30 minutes).

However, to appropriately report 99408 and 99409, the physician must document the specific amount of time he spent with the patient, which you didn’t mention.

According to the CPT^® guidelines, you should report 99408 if the provider spends 15 to 30 minutes screening a patient for abuse of alcohol or another non–tobacco substance. You would report 99409 if the provider spends more than 30 minutes screening a patient for abuse of alcohol or another non–tobacco substance. With both of these codes, the physician performs a brief intervention at the same session for the patient.

Don’t miss: For Medicare patients, you may consider reporting G0396 (Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., audit, dast), and brief intervention 15 to 30 minutes) or G0397 (… greater than 30 minutes) in place of 99408 or 99409.

Caution: You should never report 99408 in conjunction with 99409. You should also never report 99408 or 99409 in conjunction with 96160 (Administration of patient-focused health risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument) or 96161 (Administration of caregiver-focused health risk assessment instrument (eg, depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument).