Pulmonology Coding Alert

Question: If a patient sees my pulmonologist just for counseling and does not have an established illness, can I report the counseling? If so, how?


Florida Subscriber

Answer: When your physician counsels a patient who doesn't have an established illness (e.g., family history of lung CA), you can seek reimbursement.

You should report 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), or 99404 (... approximately 60 minutes), depending on the counseling session's duration.

The preventive, risk-reduction counseling codes are not the same as those for counseling patients with established medical problems, so make sure the documentation notes are clear regarding the reason the physician is counseling the patient. Use codes 99401-99404 when the patient does not have any signs, symptoms or problems--acute or chronic, stable or unstable--and the counseling concerns health maintenance or prevention rather than disease or injury.

The patient's insurer may not cover these codes or it  may only cover them when the patient's PCP provides the service. You may seek reimbursement from the patient for noncovered services as long as you meet the obligation set forth by the payer.

For Medicare, you may directly bill the patient for noncovered services. You must, however, deduct the charges for the noncovered services from the allowable charge for any other covered services provided on the same day by the same provider.

Some non-Medicare payers may only allow you to bill the patient for noncovered services when you notify the patient of possible noncoverage in advance of the service. You must check in your private payer contracts for any prohibitions.