Primary Care Coding Alert

Hint: Counseling codes cannot be used for patients with existing illness.

When your FP performs preventive counseling, you will have to report it with the appropriate counseling code depending on the time your clinician spent face-to-face with the patient. You will lose out on added reimbursement if you are not identifying appropriate opportunities to report same day E/M codes with counseling codes. 

Select Preventive Medicine Counseling Codes Based on Time

If your FP only counsels the patient during a session and the patient does not have an established illness, you should use one of these four codes, depending on the counseling session’s duration:

• 99401--Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual (separate procedure); approximately 15 minutes
• 99402--...approximately 30 minutes
• 99403--...approximately 45 minutes
• 99404--...approximately 60 minutes.

According to CPT®, examples of preventive medicine counseling and risk factor reduction interventions include situations in which a physician counsels on family problems, diet and exercise, substance abuse, sexual practices, injury prevention, dental health, and normal diagnostic and laboratory test results available at the time of the encounter.

Caution: In other words, the purpose of the visit must be promoting health and/or preventing illness or injury. If the patient is ill, you shouldn’t use the preventive counseling codes to report counseling or coordination of care related to the illness. CPT® clearly states that you should not use these codes when counseling patients with symptoms or an established illness.

For example, you have to use a preventive counseling code when your FP 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.

Learn how to determine which code to report and what documentation you need using these three scenarios.

Example 1: Master This Birth-Control Scenario

If your FP spends 15 minutes discussing and prescribing birth control pills during a preventive medicine counseling session with an adolescent patient, report 99401 and link it to V25.01 (General counseling on prescription of oral contraceptives).

When your clinician prescribes alternatives such as the contraceptive patch during a preventive medicine counseling session, link V25.02 (General counseling on initiation of other contraceptive measures) to the appropriate code for preventive medicine, individual counseling (99401-99404). You should note, however, that V25.02 excludes insertion of intrauterine devices (IUDs).

Remember: Because 99401-99404 are time-based, your physician must document the amount of face-to-face time spent counseling, and the content of the counseling is crucial. Notes for the counseling visit should include references to pamphlets or other materials your FP reviewed with the patient.

Keep in mind: If an adolescent comes in for a follow-up visit after an initial birth-control prescription, you can report a regular E/M service (99212-99215) with a birth-control diagnosis (V25.4x), because the physician is now monitoring the side effects of the drug or other contraceptive method previously prescribed. But, as most of these visits will involve counseling, you should go through this checklist to make sure your documentation has what it takes:

1. Does the documentation reveal the total face-to-face time in the outpatient setting?

2. Does the documentation describe the content of the counseling or coordination of care?

3. Does the documentation reveal that the physician spent more than half of the time in counseling or coordinating care?

If all of the answers are “Yes,” you should select the office visit E/M service level service based on the total encounter time (in minutes), but be aware that some insurance carriers ask for specific documentation that shows the time the counseling began and ended.

Best bet: You’ll stand a better chance of convincing payers to reimburse for counseling if you’re able to provide particulars on the content of the discussion and reasons the physician prescribed a certain contraceptive.

ICD-10: When your begin using ICD-10 codes after Oct.1, 2015, V25.01 will become Z30.011 (Encounter for initial prescription of contraceptive pills) and V25.02 will become one of four other ICD-10 codes, depending on the contraceptive measure initiated, if known:

• Z30.013 (Encounter for initial prescription of injectable contraceptive)
• Z30.014 (Encounter for initial prescription of intrauterine contraceptive device)
• Z30.018 (Encounter for initial prescription of other contraceptives)
• Z30.019 (Encounter for initial prescription of contraceptives, unspecified).

Also, V25.4x will become one of 8 codes depending on the type of contraceptive being followed: Z30.40-Z30.49.

Example 2: Help Yourself by Tackling HPV Problem

An established patient presents to your FP and wants counseling as to whether or not she should have the HPV vaccine. Once she learns about its benefits, she wants to have the vaccine on the same day. That means you should report:

• One of the codes from 99401-99404, depending on the time spent in the counseling
• A code such as 90649 (Human papillomavirus [HPV] vaccine, types 6, 11, 16, 18 [quadrivalent], 3-dose schedule, for intramuscular use) for the vaccine
• A code such as 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid]) for the injection.

Caution: “If the patient is 18 years of age or younger, your coding of this encounter likely changes,” observes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “In that scenario, you can appropriately report 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered) for the administration of the vaccine. 

However, if you report 90460 for the administration, then you should not report 99401-99404 for the counseling unless it extended beyond counseling related to the vaccine, since the vaccine-related counseling is included in 90460. CCI edits bundle 99401-99404 into 90460, unless a modifier, such as modifier 25, is appended to 99401-99404,” adds Moore.

Note: You should link the 99401-99404 code with V65.45 (Counseling on other sexually transmitted diseases). Also, you should link the vaccine and administration codes with a diagnosis of either V04.89 (Need for prophylactic vaccination and inoculation against certain viral diseases; other viral diseases) or V05.8 (Need for other prophylactic vaccination and inoculation against single diseases; other specified disease), depending on payer preferences.

Don’t forget: If you administer the vaccine during the same visit as the counseling, you should add modifier 25 (Significant, separately identifiable E/M service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the 99401- 99404 code, whether the vaccine administration is coded with 90460 or 90471.

ICD-10: When your diagnosis system changes in 2013, V65.45 will become Z71.89 (Other specified counseling) and codes V04.89 and V05.8 will become Z23, (Encounter for immunization). 

Example 3: Sort Out Counseling, E/M on Same Day

Your FP sees a patient for urinary incontinence (788.3x) and then spends time counseling the patient on smoking cessation. In this case, you could report the 99401-99404 codes in addition to the problem E/M code (such as 99214, Office or other outpatient visit for the evaluation and management of an established patient...) if this was general counseling regarding the benefits of quitting. 

Alternatively, you can report codes 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes) or 99407 (Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes) if your FP performed counseling as part of the treatment of condition(s) related to or made worse by the smoking.

In general, this type of counseling requires use of specific validated interventions of assessing readiness for change and barriers to change, advising a change in behavior, assisting by providing specific suggested actions and motivational counseling, and arranging for services and follow-up. You can add modifier 25 to the problem E/M code to indicate that it is distinct from the counseling. “Also, the time spent on the separately reported counseling code should not be used as a basis for selection of the problem-oriented E/M code if that E/M code is being chosen on the basis of time,” notes Moore.

Key: The urinary incontinence is not related to the smoking cessation. If the patient presents to your office for a problem visit and your doctor counsels the patient on a different issue, you can report both.