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Well visits E/M codes and Counseling codes.

Bernadette Posted Thu 10th of October, 2013 11:15:26 AM

Hello,

We have a question about the billing of Well E/M codes and Counseling codes..

When we billed a CPT code 99395-25 and CPT code 99401-33 the insurance paid on 99395-25 but denied 99401-33 as procedure not payable when performed with other related procedures on the same date of service. We used an ICD-9 code v70.0 on 99395-25 and ICD-9 code V65.40. Was this denied correctly?

We thank you for your feedback!

Bernadette Posted Thu 10th of October, 2013 15:33:28 PM

Sorry! I had to revise my qusetion a bit!:

Hello,

We have a question about the billing of Well E/M codes and Counseling codes..

When we billed a CPT code 99395-25 and CPT code 99401-33 the insurance paid on 99395-25 but denied 99401-33 as "procedure not payable when performed with other related procedures on the same date of service". We used an ICD-9 code v70.0 on 99395-25 and ICD-9 code V65.40 on 99401. Was this denied correctly?

We thank you for your feedback!

SuperCoder Answered Thu 10th of October, 2013 22:43:46 PM

You should be able to submit 99401 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]; approximately 15 minutes) in certain circumstances.

Code 99401 represents a visit because the mom-to-be wants to meet with the pediatrician because of anticipated newborn concerns. No specific problem has arisen that needs discussion, but the parents might want to talk about breastfeeding versus bottle feeding, circumcision, or other issues. Although CPT does not include language supporting use of 99401 this way, the American Medical Association (AMA) has suggested 99401 as the appropriate code for a prenatal or perinatal visit.

Consult choice: If another physician refers the mom to your practice for discussion of specific issues (such as a problem with the fetus or a problem with the pregnancy that affects the fetus), you ould report a consultation code. For example, an ultrasound shows renal abnormalities so the obstetrician refers the mother to a pediatric nephrologist to discuss the issue and potential treatment options. The pediatrician could submit the appropriate consultation choice from 99241-99245 (Office consultation for a new or established patient ...).

In either situation, report diagnosis V65.11 (Pediatric pre-birth visit for expectant parent[s]).

Be aware: Insurance companies might -- or might not -- pay fo a "get acquainted" visit during the mom's pregnancy, so know your payers' guidelines. Some physicians view these visits as good public relations/practice builders and don't charge the patient or report the encounter to the insurer. If you file, report the best code from the 99401 series and include diagnosis V65.11 (Pediatric pre-birth visit for expectant parent[s]).

Bernadette Posted Fri 11th of October, 2013 13:02:41 PM

Thanks for your response but we need more info as this was not about a pre-natal visit.

We are primary care pediatric physicians. The patient came in for a well visit. Patient is 18 years old and is obese. The doctor examed the patient and counseled the patient on nutrition and exercise. We billed cpt code 99395-25 with icd-9 code v70.0 for the well visit. For the counseling code, we billed 99401-33 with icd-9 codev65.40. We did get paid on 99395-25 but they denied 99401-33 for "procedure not payable when performed with other related procedures on the same date of service". Is there something we should be doing to have this counseling code processed for payment during our patients' well visits? We have read the info on cpt code 99401 on Supercoder and we just need clarification as to this situation.

Thanks!

SuperCoder Answered Mon 14th of October, 2013 08:09:24 AM

The 99401-404 counseling codes are for risk reduction (anticipatory counseling), which most payers rightly consider included in the preventive medicine codes. When these codes were originally valued, they included 15 minutes of preventive medicine counseling. If there is a significant problem warranting a significant amount of time for additional counseling, it should be billed with an E/M code based on time. This should be well documented with separate documentation and a distinct supporting ICD diagnostic code. But in many cases, the insurance company is right in denying these.

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