We've all heard the adage, "An ounce of prevention is worth a pound of cure." It seems that medicine has heeded this warning. Preventive medicine, which is aimed at protecting, promoting and maintaining health, is also a medical specialty recognized by the American Board of Medical Specialties[i]. CPT coding reflects the importance of preventive medicine as there is an entire listing of preventive codes within the E/M section of the CPT manual. This article will focus on a subsection of preventive medicine coding: coding for preventive counseling visits.
The range of CPT codes 99401-99404 is used to report counseling to individuals when the counseling is of a preventative nature. These codes are defined by the American Medical Association (AMA)[ii] as:
- CPT code 99401: Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure)Íž approximately 15 minutes
- CPT code 99402: approximately 30 minutes
- CPT code 99403: approximately 45 minutes
- CPT code 99404: approximately 60 minutes
There are some important guidelines to adhere to when billing these codes. This set of codes is used to report face-to-face services for the purpose of promoting health and preventing injury. These services may be reported separately from an E/M service by appending modifier -25 to the E/M services when performed. However, these codes may not be reported with preventive medicine codes within in the range of 99381 - 99397. The CPT Assistant issued March 2016, clarifies that preventive medicines codes 99381 - 99397 "include counseling/anticipatory guidance/risk factor reduction interventions, which are provided at the time of the initial or periodic comprehensive preventive medicine examination".
However, payer guidelines and policies may differ from the coding guidelines set forth by the AMA. For instance, Mississippi's Magnolia Health plan offers claims filing instructions for submitting EPSDT (Early and Periodic Screening, Diagnostic and Treatment) services. "Appendix VI: Submitting EPSDT Services" found within the Magnolia Health Claims Filing Manual[iii] instructs providers that the adolescent counseling screening code (CPT 99401 for children 9-21 years of age) as well as the vision and hearing screening CPT codes, must be billed in conjunction with the comprehensive age appropriate screening, or preventative medicine visit from the code range 99381 - 99395. The guidelines also instruct providers to append modifier -EP to all EPSDT service codes.
Lastly, as these codes are timed codes; meaning each code has a time threshold supporting anywhere from 15 - 60 minutes of face-to-face time spent, documentation should include the amount of time spent in counseling.
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[ii] American Medical Association. 2016 AMA CPT Professional Edition, Chicago, IL: AMA, 2015
