Primary Care Coding Alert

End risk factor reduction and behavior change intervention confusion.

What happens when a patient comes in for a preventive medicine service, and during the visit your provider reviews the pertinent lab and clinical findings to uncover behaviors that could potentially pose a threat to the patient’s well-being?

Very likely, your provider will use the opportunity to open a dialog with the patient about the behavior in question, which means that you will need to dig into the risk factor reduction or behavior change intervention codes.

But before you do, you should read on. Because you’ll need to know the differences among the codes and which codes you cannot report with them.

Know the Relationship Between Preventive Medicine and Risk Factor Reduction

Risk factor reduction is a form of preventive medicine that focuses on “promoting health and preventing illness or injury,” according to CPT^®. The services “should address such issues as family problems, diet and exercise, substance use, sexual practices, injury prevention, dental health, and diagnostic and laboratory test results available at the time of the encounter,” CPT^® continues.

In other words, “all of the conversation/counseling involved in 99401-99404 [Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure)…] and 99411-99412 [ … provided to individuals in a group setting …] is an integral part of the 99381-99397 [Initial/Periodic comprehensive preventive medicine evaluation/reevaluation and management of an individual …] visit,” according to Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, New Mexico.

This means you should not report 99401-99404 or 99411-99412 for the same patient on the same date you report a preventive medicine visit with 99381-99397. As the CPT^® descriptors for 99401-99404 and 99411-99412 note, they represent a “separate procedure” when the preventive medicine counseling is done independent of a preventive visit.

“The conversation/counseling may take of the form of discussing things like accident prevention, nutrition, family relationships, and immunizations with the parents of a minor,” Witt continues. “In the case of an adult, it might be discussion on how to prevent heart disease, bone loss, the benefits of losing weight, unsafe sexual practices, and the like.”

The provider initiates the counseling after he or she reviews “any pertinent laboratory and clinical findings found during the preventive visit,” Witt adds. Then, the provider “identifies and informs the patient about the risk factors, informs the patient about their impact on the patient’s health, and discusses options with the patient for reducing the identified risks.”

It’s also important to remember that the preventive medicine counseling codes are not problem-oriented. As the CPT^® guidelines preceding the codes note, “Risk factor reduction services are used for persons without a specific illness for which the counseling might otherwise be used as part of treatment.”

Know Risk Factor Reduction, Behavior Change Intervention Differences

CPT^® explains that “behavior change interventions are for persons who have a behavior that is often considered an illness itself.” In other words, “the behavior change intervention codes are used to assess/treat patients with tobacco abuse/dependence or alcohol/substance abuse/dependence,” according to JoAnne M. Wolf, RHIT, CPC, CEMC, AAPC Fellow, coding manager at Children’s Health Network in Minneapolis, Minnesota. So, you’ll report either 99406-99407 (Smoking and tobacco use cessation counseling visit …) or 99408-99409 (Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services …) depending on the patient’s circumstances.

Know Why You Can’t Report 96150-96155 with 99401-99412

Confusingly, CPT^® lists several other health and behavior assessment/intervention codes — 96150-96151 (Health and behavior assessment … initial/re-assessment) and 96152-96155 (Health and behavior intervention …) — that seem similar on the surface. “The assessment focuses on factors related to the patient’s physical health, including issues such as taking medications, and complying with medical advice, in order to come up with a treatment plan for the patient, while the intervention codes involve using the assessment to develop an intervention that will work for the patient in changing the unhealthy behaviors,” says Witt.

Importantly, you cannot report these codes with 99401-99412. “That’s because 96150-96155 are used for patients presenting with an illness or a health problem,” says Wolf. “So, it would be inappropriate to report these codes with 99401-99404 or 99411-99412, which are used for patients without a specific illness.” In addition, “risk factor reduction, which consists of general counseling, would be included as part of a more targeted assessment or counseling represented by codes 96150-96155,” says Witt.

Coding alert: CPT^® Assistant (March 2002) also notes another difference between the two code sets. Codes 96150-96155 “may be reported by, but are not limited to, psychologists, advanced practice nurses, clinical social workers, and other non-physician healthcare professionals within their scope of practice …. These codes are not intended to be used by physicians.” You would report a physician providing these services for a patient with a specific illness using an evaluation and management (E/M) code from 99201-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …). CPT^® 2019 has a similar parenthetical instruction preceding code 96150.

Know Why Counseling Time Can’t Count for E/M Service Selection

Finally, because they are counseling services, each of the 99401-99412 codes have times incorporated in their descriptors. CPT^® guidelines for the codes state, in part, that “any E/M services reported on the same day must be distinct and reported with modifier 25, and time spent providing these services may not be used as a basis for the E/M code selection.”

The reason for this is pretty simple: “The time counted toward the counseling is for a separate purpose and may not be counted toward the evaluation of the problem,” says Witt. “That would be double-dipping.”