Pediatric Coding Alert

Dana Klar, practice manager for Mount Sinai Medical Associates in New York City, writes, What is the best way to code for preventive counseling?

Pediatricians tend to spend a lot of time and energy on counseling. And although there are counseling codes, there is some doubt about how to use them.

The counseling codes -- 99401, 99402, 99403, and 99404 for individual, CPT 99411 and 99412 for group -- are a part of preventive medicine. They are to be used when you counsel patients/parents at a separate encounter from a well-child visit. According to CPT, the counseling codes, which are also for risk-factor reduction, vary with age and should address such issues as 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.

99401: 15 minutes of individual counseling
99402: 30 minutes of individual counseling
99403: 45 minutes of individual counseling
99404: 60 minutes of individual counseling

Note: Individual counseling can be to the parent or patient.

These codes are not to be used in connection with symptoms or established illnesses. You should use the appropriate office visit code or other evaluation and management code for such services.

When would you use these codes? Lets say an adolescent girl comes in and has an UTI, says Wendy Evans, CMM, practice administrator for Countryside Pediatrics in Sterling, VA. And this young lady has previously had four UTIs. The pediatrician wouldnt have half an hour blocked out to talk about sexuality at this time. But he asks her to come back another time for an appointment, and spends 30 minutes educating her on safe sex, the use of condoms, and discussing birth control. This would definitely be a 99402, says Evans.

What if the pediatrician decides to do the counseling on the same day? You could use an office visit code for the UTI, and then use a 25 modifier for the counseling -- although many insurance companies would reject this. Some health plans will take it with a modifier, admits Evans. And some wont.

Another scenario offered by Evans is a six-month-old baby who comes in with a mother who smells of cigarette smoke. The doctor may spend 45 minutes talking to the parent about the ill effects of smoking on the child, she says. This would be coded as 99403. (Evans works for Charles Schulte, MD, FAAP, who is well-known for his efforts in preventive medicine.)

Not all pediatricians can spend this amount of time on counseling, however. Its a frou-frou, says Victoria S. Jackson, administrator/CEO of Southern Orange County Pediatric Associates, Lake Forest, CA. Not one of the insurance companies in California will pay on the counseling codes, she says. But can they be used? Yes, and thats what theyre for -- counseling.

In states where managed care organizations are more forthcoming on reimbursing these codes, you would even be able to use the group counseling codes, says Jackson. Her practice, for example, provides group education services to children. One talk may be about tobacco. These codes are 99411 for group preventive medicine counseling lasting 30 minutes, and 99412 for these sessions lasting 60 minutes. Even if you dont get reimbursed for such sessions, says Jackson, theyre valuable to a practice. Thats PR, and you cant put a tangible amount on it.

The one circumstance under which Jackson does file a counseling code is when the parent makes an appointment to talk with the provider about something specific -- either with the mother or her child -- that is not illness-related. Then its truly preventive medicine, she adds, stressing that it must be a separate encounte