Wiki Contraception counseling & Acute problem

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SUEV

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I understand that when the provider discusses contraception, the visit should be coded with the 99401-99404 codes which are based on 15 minute increments. I have a provider who saw a patient for an acute problem as well as contraception. The documentation shows over 50% of this 30 minute visit was spent on counseling for both the UTI and Contraception. Since I don't have a specific time for the preventive/risk factor reduction counseling, how should I handle this one? Technically the 99401 isn't supported since the contraception time isn't separated out. A 99214 is not supported based on the low MDM for the UTI (our organization has a policy NOT to include Rx Mgmt to figure out the level of risk). Any suggestions?
Thanks,
Sue
 
Is the other 50% of the time documented with the provider giving the patient an exam? The provider had to derive at the conclusion that the patient has a UTI in some type of way. In order to bill for a 99212 and up, an exam has to be performed.
 
SUEV said:
I understand that when the provider discusses contraception, the visit should be coded with the 99401-99404 codes which are based on 15 minute increments. I have a provider who saw a patient for an acute problem as well as contraception. The documentation shows over 50% of this 30 minute visit was spent on counseling for both the UTI and Contraception. Since I don't have a specific time for the preventive/risk factor reduction counseling, how should I handle this one? Technically the 99401 isn't supported since the contraception time isn't separated out. A 99214 is not supported based on the low MDM for the UTI (our organization has a policy NOT to include Rx Mgmt to figure out the level of risk). Any suggestions?
Thanks,
Sue
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It is difficult to answer your question based on the information provided. The entire session may fall into preventive/risk factor reduction counseling or treatment of an acute illness. It is often necessary to discuss contraception to decrease the risk of UTI. Women are much more likely to develop a UTI than men. Some of the risk factors are:
Frequent sexual intercourse
Having unprotected sex
Using a diaphragm for birth control or
Having a partner who uses condoms with spermicidal foam
So you can see that a discussion regarding contraception management is vital to a discussion regarding UTI prevention.

I would report the service with a standard EM code (99214) using ICD-9 CM codes 599.1, the bacteria if known, and the appropriate V25 code?
 
99214 for a problem focused issue with one body system is a little high. The MDM alone does not justify that level of care.
 
Pt request for contraception

Thank you for your responses. The note does not tie in the contraception (preventive) with the UTI (problem) which is why I'm hesitant to code the 99214 based on time. The reason for the appt was frequent urination but in regards to the contraception, the HPI also states "Looking for new contraception...Had trouble remembering to take the pills...Wondering about IUD". So the contraception discussion was initiated by the patient, not the provider. GaPeach77
The plan for the contraception states "Educated patient about the various forms of birth control, their benefits, and their risks: including OCP, nuvaring....She would like to try...."

The UTI was treated with an antibiotic.

There is a Detailed Hx, EPF Exam (including abdomen and back) and Low MDM.

Does the above change anyone's opinion? It has also been suggested to assume the 15 minute threshold has been met for the 99401 and bill it along with the 99213. Thank you for your input.
 
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