Pediatric Coding Alert

Question: I have a teen patient who is going abroad with his family and the patient's mother is being fairly insistent that she wants to take antibiotics for the child with her "just in case" he gets sick while they are there. Because they are going to a major city with many medical facilities, I don't feel that a prophylactic antibiotic prescription is warranted so I refused to give the prescription. During our face-to-face visit, I did recommend that they take over-the-counter probiotic Florastor before and during their trip to help with any potential intestinal issues. Which CPT® code should I report for this visit?

California Subscriber

Answer:  In most cases, you'll report a code from the 99401-99404 series (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual). According to CPT®, these codes describe "services provided face-to-face by a physician or other qualified health care professional for the purpose of promoting health and preventing illness or injury," and are selected based on the time required for the service in 15-minute increments.

Another option would be to use a time-based E/M code related to the counseling for this patient's trip and potential anticipated problems (99212-99215).