Primary Care Coding Alert

Question: Can we bill an evaluation and management (E/M) service such as 99213 with counseling code 99406 on the same date by the same physician? Can we also bill for Do Not Resuscitate (DNR) counseling on the same day as the E/M code?

Washington Subscriber

Answer: The CPT^® guidelines for Preventive Medicine Services that accompany 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes) state that “if an abnormality is encountered or a preexisting problem is addressed” during the service, and “if the problem or abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate Office/Outpatient code 99201-99215 should also be reported.”

Likewise, the guidelines for Counseling Risk Factor Reduction and Behavior Change Intervention in the Preventive Medicine Services section of CPT^®, where 99406 is found, state these codes “are distinct from evaluation and management (E/M) services that may be reported separately with modifier 25 when performed.”

As 99213 (Office or other outpatient visitfor the evaluation and management of an established patient …) is listed in those codes, you can report the two services together, remembering to add modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service) to indicate that the provider performed a significant, separately identifiable E/M service on the same day as the preventive medicine service.

The same would be true if you report 99497 (Advance care planning including the explanation and discussion of advance directives such as standard forms [with completion of such forms, when performed], by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member[s], and/or surrogate) with or without its add-on code 99498 (… each additional 30 minutes). The CPT^® guidelines preceding 99497 and 99498 state that they “may be reported separately if these services are performed on the same day as another Evaluation and Management service.” Once again, modifier 25 would be appended to the problem-oriented E/M code, such as 99213, to indicate that you are documenting the service separately.

Along with reporting the CPT^® codes for the services, you’ll also need to add the appropriate ICD-10-CM codes to document the encounter. So, you would add Z71.89 (Other specified counseling) to 99497 plus Z66 (Do not resuscitate), providing your caregiver and patient have discussed and completed a written directive such as a health care proxy, a durable power of attorney for health care, a living will, or medical orders for life-sustaining treatment (MOLST) that includes a DNR order. And you would also add Z71.6 (Tobacco abuse counseling) to 99406 for the smoking counseling session.