E&M Coding Based on Time & Counseling Services
By Erica Schwalm
Preventive counseling and/or risk factor reduction codes (99401 – 99404) are used to report services provided to individuals at a separate encounter for the purpose of promoting health and preventing illness. Preventive counseling done during any other visit is considered bundled into the visit and not billed separately. If a patient comes in only for preventive counseling, such as contraceptive counseling or counseling for family problems, then you should bill a code from this series. The codes are based on time only (no history, exam or medical-decision making needed.) The diagnosis should be a V-code.
99401 – 15 Minutes 99402 – 30 Minutes
99403 – 45 Minutes 99404 – 60 Minutes
For counseling individuals with symptoms or established illness, use the appropriate office, hospital or consultation or other evaluation and management codes.
If more than 50% of the visit is spent on counseling or coordination of care, time becomes the key factor in choosing the level of service. (The time “overrides” the requirements for history, exam, & medical decision making.) The total time of the visit should be documented as well the amount of time and nature of the counseling and/or activities to coordinate care. Only E&M codes that have “typical times” in their code descriptors are subject to these guidelines. (e.g. 99213 – 15 min., 99214 – 25 min., etc. See CPT manual)
An established patient, who has no health problems, wants to lose a few pounds (but is not considered overweight or obese) and comes in for some health advice before joining the gym. You spend about 15 minutes counseling the patient on healthy food choices and exercise. You would bill a 99401 with a v-code diagnosis such as V65.3. This type of counseling is strictly preventive because the patient has no health issues.
A different established patient, who is morbidly obese and recently diagnosed with type II diabetes, comes to the office. You spend 25 minutes counseling her on the importance of diet and exercise to control the diabetes and obesity. In this case, the patient has an established illness, so the counseling is not preventive; it's a necessary part of the treatment. You would then bill a 99214 w/ 250.00 and 278.01.
One final note: Not all payors cover preventive counseling codes (99401 – 99404). Medicare does not cover this service. If a Medicare patient came in strictly for preventive counseling, patient should sign an ABN.