Primary Care Coding Alert

When doctors counsel patients on disease care or preventive health, they should be paid for their time. However, many offices are unsure how to code for counseling time. The result is a loss of significant, earned revenue.
 
There are two basic ways to code counseling services:
  Use the 99401-99404 series of preventive medicine counseling codes.
  Use the time component of an E/M visit (e.g., 99211-99215).

Differentiating Between the Two Is Easy

 
When the patient presents for counseling on a known problem, use the time component of an E/M visit. When the patient seeks counseling to avoid a problem, use the counseling codes, says Susan Callaway, CPC, CCSP, an independent coding and reimbursement consultant based in North Augusta, S.C.
 
It may sound simple, but frequently coders do not recognize the difference. Ask this key question when choosing a code: Does the patient have symptoms of, or has he or she been diagnosed with, an illness or disease that is the subject of the discussion?

Counseling Codes Have Limited Use

 
The counseling codes are used when the physician sees a well patient for counseling and/or risk-factor reduction. Choose the correct code based on the time spent counseling, beginning with 99401 (preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]; approximately 15 minutes) and extending to 99404 ( approximately 60 minutes).
 
The purpose of the visit must be promoting health and/or preventing illness or injury. If the patient is ill, the counseling codes should not be used. For example, use a counseling code when the doctor provides counseling on diet and exercise for a well patient who wants to lose weight, but not when the doctor provides the same services to a diabetic.
 
The preventive medicine counseling codes have a fairly limited use, says Emily Hill, PA-C, president of Hill & Associates, a consulting firm in Wilmington, N.C., that works with physician practices on coding and compliance. They cannot be billed with any other service on the same day.
 
A physicians office, for example, cannot use 99401  with a preventive medicine office visit code, e.g., 99381-99397, because that series includes counseling time in its reimbursement schedule. The physicians office also cannot use a counseling code with an E/M code .
 
According to CPT, counseling codes apply when a physician counsels on family problems, diet and exercise, substance abuse, sexual practices, injury prevention, dental health, and diagnostic and laboratory test results available at the same time of the encounter.
 
Callaway gives an example: A mother makes an appointment for her teen-age daughter to see the family physician because of concerns that the girl is sexually active. There is no symptom or established illness; the girl is not pregnant and has no sexually transmitted diseases. The physician counsels the girl, discussing such issues as safe sex and birth control. The visit lasts 30 minutes and is coded 99402 (preventive medicine counseling; approximately 30 minutes). The physician should document the time spent and outline in detail the topics discussed.
 
Note: If the physician provides this counseling as part of a regular preventive medicine exam, e.g., 99394, the counseling time is included in that code and a separate counseling code cannot be used.
 
Reimbursement for the counseling codes is limited. Medicare and most private insurers will not pay. When using the counseling codes, Hill says, physicians offices should advise patients in advance that the visit likely will not be covered by their insurance carriers. An advance beneficiary notice (ABN) should be signed by Medicare patients, while other patients can be advised verbally. Patients can then be billed for the charges.
 
The group-counseling code series is used infrequently. Choose 99411 (preventive medicine counseling and/or risk factor reduction intervention[s] provided to individuals in a group setting [separate procedure]; approximately 30 minutes) or 99412 ( approximately 60 minutes) based on time. Examples for use of these codes include an educational program, presented to new parents with well babies, to help reduce the incidence of otitis media, or a program on infant feeding.

Use the Time Component Correctly

 
Most providers will use the time component of an E/M visit instead of the counseling codes, Hill says.
 
These codes can be problematic for coders, so Callaway says many family physician offices fail to get reimbursement for time the doctor spends counseling.
 
For example, a woman with symptoms of diabetes, including fatigue and headache, visits her family physician. The doctor orders a complete panel of tests and asks her to return in a week for the results. Test results show diabetes. At the follow-up visit, the doctor gives the results and counsels her on the disease and its treatment, but performs no exam and takes no history. The visit lasts 45 minutes. It is coded 99215 (office or other outpatient visit for the evaluation and management of an established patient) using the time component.
 
A common mistake many doctors make is to code a lower-level 99212 (office or other outpatient visit for the evaluation and management of an established patient) because they dont understand fully how to use the time component.
 
When I deal with doctors offices, that is probably the least understood and most underutilized mechanism for billing, Callaway says.
 
The doctors will note that they did not take a history or perform an exam, and therefore believe they have to code a lower-level 99212, she says. If counseling or coordination of care equals half or more of the face-to-face time, the coder can use time as the key factor in selecting the level of E/M service.
 
The difference in reimbursement between 99212 and 99215 is significant. Code 99215, with a relative value unit (RVU) of 3.20, has a Medicare allowance (national, not adjusted for region) of $115.84, compared to $36.20 for a 99212, which has an RVU of 1.00.
 
Medicares bell curve shows that 2.7 percent of a practices established patient billings are typically for 99215, and a good portion of those should be these 40- to 45-minute counseling visits, Callaway said.
 
One other important note in calculating the time component: You can use the entire time the doctor spent with the patient, not just the time spent counseling, in calculating time, Hill says.
 
For example, if the doctor performed an exam and took the patients history for 15 minutes, then counseled the patient for 30 minutes (more than half of the time), the criterion for 99215 (40 minutes of face-to-face time with the patient or family) would be met. Carefully document how the doctors time was spent.

Use Prolonged Services Codes 
 
 
Occasionally time spent counseling a patient will go beyond the time limits of the highest-level E/M code, e.g., 99215. Using the prior diabetic example, this might happen if the woman is confused by the diagnosis and treatment and calls a family member halfway through the discussion to listen, causing the doctor to begin again.
 
If the visit extends to one hour and 10 minutes, or 30 minutes past the longest E/M time, use a prolonged services code such as 99354 (prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting]; first hour) in addition to the E/M code. Document the reason for the extended counseling in the patients record.
 
Most insurance companies will pay without question, Callaway says.
 
If the additional time is less than 30 minutes, you can append modifier -21 (prolonged evaluation and management services) to the E/M code, e.g., 99215. However, many carriers will not provide additional reimbursement for modifier -21, and those that do usually require the office to submit written documentation. Typical payment, if successful, is about $10.
 
By comparison, the prolonged services codes usually result in added payment of about $80.