Pediatric Coding Alert

Question: An established patient's parents came in without their teenage son to discuss his behavior problems linked to suspected drug and alcohol use. Can we code for the parent-only counseling session?

Washington Subscriber

Answer: CPT does allow you to report new and established patient office visits without the patient present. When counseling and/or coordination of care account for more than 50 percent of the face-to-face time that the physician spends with the patient and/or family, you may use time as the key factor when determining the E/M service level. In these cases, you do not have to use history, examination and medical decision-making as the key factors. Because counseling comprises the majority of the visit you describe, you should assign 99212-99215 (Office or other outpatient visit for the E/M of an established patient ...) based on time.

When coding based on time, make sure you document the encounter's total time, time spent on counseling and/or coordination of care, and the discussion topics. For instance, a note supporting 99214 (... physicians typically spend 25 minutes face-to-face with the patient and/or family ...) with 15 minutes spent counseling the parents and 10 minutes reviewing the patient's history could state, "Total time: 25 minutes; Counseling time: 15 minutes; Discussed signs of possible drug/alcohol use, handling behavior problems."

Beware: You may receive a denial depending on the patient's diagnosis. Some insurers have mental-health carve outs that limit mental-health diagnoses coverage to services provided by mental-health practitioners.