Gustavo Posted Thu 27th of June, 2013 14:59:02 PM
Patient comes in with father to discuss the use of muscle supplements that son is taking and its adverse effects on his health. Patient doesn't have any symptoms or diagnosis. How can we code this visit? What ICD9 code should we use? Would this be considered a counseling?
SuperCoder Answered Fri 28th of June, 2013 03:18:07 AM
I have forwarded this query to my Pediatric editor. She will work on this and will reply soon.
SuperCoder Answered Fri 28th of June, 2013 13:23:06 PM
You can use 99401-99404. These are time based codes.
These codes are used to report services provided face-to-face by a physician or other qualified health care professional for the purpose of promoting health and preventing illness or injury. They are distinct from evaluation and management (E/M) services that may be reported separately when performed. Risk factor reduction services are used for persons without a specific illness for which the counseling might otherwise be used as part of treatment.
SuperCoder Answered Mon 01st of July, 2013 20:45:15 PM
Adding more on this :
The visit can be coded based on time spent as long as more than 50% of the visit is spent counseling/coordinating care (and it sounds like this one was). They need to be sure to document the total time spent, the time spent counseling, and the counseling topic. For ICD-9, they can report the most appropriate V code such as V65.42, V65.3, or V65.49, among others. The pediatrician should select the code that most accurately fits the visit.