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Coding Consult: Make sure you're paid for counseling


Doctors often undercode their work when they merely give advice or information. Here's what you need to think about to get paid properly.


Coding Consult

Make sure you're paid for counseling

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Choose article section... For E&M codes, use the time component correctly Use prolonged service codes when you exceed time limits

Doctors often undercode their work when they merely give advice or information. Here's what you need to think about to get paid properly.

When you counsel patients on disease care or preventive health, you should be paid for your time. Many doctors, however, are unsure how to code for counseling time. The result is a loss of significant earned revenue.

To code for counseling services, you can use either the 99401-99404 series of preventive medicine counseling codes or the time component of an E&M visit (e.g., 99211-99215).

That may sound simple, but frequently coders don't recognize the difference. You need to ask this when choosing a code: Does the patient have symptoms of, or has she been diagnosed with, an illness or disease that is the subject of the discussion?

The counseling codes are used when the physician sees a well patient for counseling or risk-factor reduction. Choose the correct code based on the time spent counseling, beginning with 99401 (preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]; approximately 15 minutes) and extending to 99404 (approximately 60 minutes).

The purpose of the visit must be to promote health or prevent illness or injury. If the patient is ill, don't use the counseling codes. For example, use a counseling code when you provide advice on diet and exercise for a well patient who wants to lose weight, but not for a diabetic.

"The preventive medicine counseling codes have a fairly limited use," says Emily Hill, president of Hill & Associates, a consulting firm in Wilmington, NC, that works with physician practices on coding and compliance. "They can't be billed with any other service on the same day."

According to CPT, counseling codes apply when a physician counsels on family problems, diet and exercise, substance abuse, sexual practices, injury prevention, dental health, and diagnostic and lab test results available at the same time of the encounter.

Susan Callaway, an independent coding and reimbursement consultant based in North Augusta, SC, gives an example: A mother, concerned that her teenage daughter is sexually active, makes an appointment for her. There is no symptom or established illness; the girl is not pregnant and has no sexually transmitted diseases. The physician counsels the girl, discussing such issues as safe sex and birth control. The visit lasts 30 minutes and is coded 99402. The physician should document the time spent and outline in detail the topics discussed.

Medicare and many private insurers won't pay counseling codes. When using them, Hill says, you should advise patients in advance that it's quite possible that their insurer won't cover the visit. Medicare patients need to sign an advance beneficiary notice; you can advise other patients verbally. Then bill patients for the charges.

For E&M codes, use the time component correctly

"Most providers will use the time component of an E&M visit instead of the counseling codes," Hill says.

These codes can be problematic, says Callaway. For instance, a woman with symptoms of diabetes, including fatigue and headache, visits your office. You order a complete panel of tests and ask her to return in a week for the results. Test results show diabetes. At the follow-up visit, you give the results and counsel her on the disease and its treatment, but perform no exam and take no history. The visit lasts 45 minutes. You should use code 99215 (office or other outpatient visit for the evaluation and management of an established patient) using the time component.

Many doctors mistakenly code a lower-level 99212 because they don't understand fully how to use the time component. "When I deal with doctors' offices, that is probably the least understood and most underutilized mechanism for billing," Callaway says.

The doctors will note that they didn't take a history or perform an exam, and therefore believe they have to code 99212, she says. However, if counseling or coordination of care equals half or more of the face-to-face time, you can use time as the key factor in selecting the level of E&M service.

The difference in reimbursement between 99212 and 99215 is significant. Code 99215, with a relative value unit (RVU) of 3.20, has a Medicare allowance (national, not adjusted for region) of $115.84, compared to $36.20 for a 99212, which has an RVU of 1.00.

One other important note: "You can use the entire time the doctor spent with the patient, not just the time spent counseling, in calculating time," Hill says.

For example, if you spent 15 minutes doing an exam and taking the patient's history, then counseled the patient for 30 minutes (more than half of the time), you've met the criteria for 99215 (40 minutes of face-to-face time with the patient or family). Carefully document how you spent your time.

Use prolonged service codes when you exceed time limits

Occasionally, time spent counseling will go beyond the time limits of the highest-level E&M code. Using the prior diabetic example, say the woman is confused by the diagnosis and treatment and calls in a family member halfway through the discussion, and that means you have to begin again.

If the visit extends to one hour and 10 minutes, or 30 minutes past the longest E&M time, use a prolonged-services code such as 99354 (prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service; first hour) in addition to the E&M code. Document the reason for the extended counseling.

"Most insurance companies will pay without question," Callaway says.

If the additional time is less than 30 minutes, you can append modifier –21 (prolonged evaluation and management services) to the E&M code. However, many carriers will not provide additional reimbursement for modifier –21, and those that do usually require the office to submit written documentation. Typical payment, if you get any, is about $10.

By comparison, the prolonged services codes usually result in added payment of about $80.

This information provided by The Coding Institute. For a free sample issue or information on how to subscribe to any of 29 specialty-specific coding newsletters, please contact The Coding Institute, 2272 Airport Rd. South, Naples, FL 34112; phone 800-508-2582; fax 800-508-2592; or visit


Coding Consult: Make sure you're paid for counseling. Medical Economics 2002;11:24.

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Jennifer N. Lee, MD, FAAFP
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