Primary Care Coding Alert

Question: We have just started using the counseling risk factor reduction and behavior change intervention codes, and we are wondering about the best way to document 99401-99412.

New York Subscriber

Answer: The descriptors to 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 …) along with 99406-99407 (Smoking and tobacco use cessation counseling visit …) and 99408-99409 (Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services …) all feature time parameters, so at the very least, your documentation will need to incorporate the actual times for the counseling or intervention.

In addition, the American Academy of Family Physicians recommends your documentation includes a synopsis of the counseling. (Source: www.aafp.org/fpm/2012/0700/p12.html#fpm20120700p12-bt4).

Last, as these are preventive services, you cannot pair problem-oriented ICD-10 codes with 99401-99412. Instead, you need to use an appropriate encounter code such as the ones listed below.