Pediatric Coding Alert

Question: Insurers aren't paying 99408-99409 (behavior change intervention) for a nutritionist counseling an obese child. When counseling dominates the encounter, could I combine the pediatrician and nutritionist "counseling" time toward the total visit and bill an E/M code instead? For instance, if a pediatrician sees a patient with obesity for 10 minutes and then a nutritionist has a 30-minute counseling session with the patient, could I use 99214? If not, could I use 99401-99404?

Colorado Subscriber

Answer: You're overlooking the best option for this scenario. When a nutritionist counsels an obese patient, a medical nutrition therapy code (97802-97804) is most appropriate. Code the counseling portion with 97803 x 2 (Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes) and the physician session with 99212 -- both linked to obesity (278.00, Obesity, unspecified; or 278.01, Morbid obesity).

For the counseling portion, use the additional diagnosis of V65.3 (Dietary surveillance and counseling). Although CPT does not require modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to indicate that the office visit is a significant, separately identifiable E/M service from the MNT, some payers may require modifier 25 on 99212 for system recognition and payment.

Many insurers, including Medicare, require nutritionists, such as licensed dietitians/nutritionists, to report MNT codes directly using their own national provider identifier. You can enter both items on the same claim by entering the different NPIs in box 24J on the revised CMS-1500 form.

Don'ts: Because nutritionists cannot report higher-level E/M services (99212-99215, Office or other outpatient visit ...), you should not combine time counseling that a nutritionist provides with a physician's E/M time. "Time-based coding is based specifically on the physician's time, NOT the allied health professional's time," says the American Academy of Pediatrics.

In the cases you describe, the patient already has a known diagnosis. Therefore, counseling and/or risk factor reduction intervention codes (99401-99404) are inappropriate. "Risk factor reduction services are used for persons without a specific illness," according to the codes' introductory notes.

Non-coverage: You should not use 2008-introduced codes 99408-99409 (Alcohol and/or substance [other than tobacco] abuse structured screening [e.g., AUDIT, DAST], and brief intervention [SBI] services; ...). These codes describe the physician first screening the patient for alcohol and/or substance (other than tobacco) abuse and then providing brief intervention services. The patients do not come in for counseling for a known disease or illness.