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Pediatric Coding Alert

Reader Questions:

250.01 Makes 99401-99404 Inappropriate

Question: Can I use 99401-99404 when a pediatrician talks to a patient about diabetes?

New York Subscriber Answer: It depends on whether the patient is already diagnosed with diabetes, such as 250.01 (Diabetes mellitus without mention of complication; type I [juvenile type], not stated as uncontrolled). If you are using a diabetes ICD-9 code, the answer is no. The patient already has an illness -- diabetes -- making him exempt from the preventive medicine counseling/risk factor reduction codes.
Codes 99401-99404 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure] ...) are for counseling of a patient without symptoms or established illness. For instance, if the pediatrician counsels at a separate visit an at-risk patient on obesity prevention to avoid diabetes and the warning signs, use 99401-99404 based on time. Example: For 15 minutes of preventive medicine counseling/risk factor reduction, report 99401 (... approximately 15 minutes) with V65.49 (Other specified counseling). This counseling must take place at an encounter distinct from an office visit.
Alternative: If the patient sees the pediatrician because the child doesn't want to do blood checks because "they're painful," you should instead report an established patient office visit code (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...).