Primary Care Coding Alert

Question: Our provider saw a husband and wife together and counseled them on travel medicine and immunization services prior to a trip abroad that the two were planning to make. The provider spent 25 minutes out of a 30-minute appointment on the counseling and wants to bill a 99214 for each patient, stating both patients had made individual appointments and that he would have given the same information to both of them had the patients been seen individually. Is this accurate, or should the time be split as each patient was not counseled individually for the 25 minutes?

Codify Subscriber

Answer: In terms of time, your provider met the criteria for 99214 (Office or other outpatient visit for the evaluation and management of an established patient. ... Typically, 25 minutes are spent face-to-face with the patient and/or family.) in this encounter.

However, as neither patient presented with a problem, 99214 would not be appropriate. Counseling regarding travel medicine and immunization would be regarded as preventive in nature, so a code from 99401-99429 Counseling Risk Factor Reduction and Behavior Change Intervention codes would be more accurate. CPT^® guidelines for those codes make this clear: “Risk factor reduction services are used for persons without a specific illness for which the counseling might otherwise be used as part of treatment.”

But this does not mean you should reach for 99402 (Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes) and bill it twice in this situation. Even though the code meets the time requirement of your provider’s situation, the descriptor clearly states that this is a service “provided to an individual.” Your provider counseled two people together, which means 99411 (Preventive medicine counseling and/or risk factor reduction intervention(s) provided to individuals in a group setting (separate procedure); approximately 30 minutes) would be most appropriate in this circumstance, as it not only meets the time requirement, but it also addresses the group nature of the counseling. Because the code describes counseling provided to “individuals in a group setting,” you may report it once for each person in the group (i.e. the husband and wife in this scenario).