99401 – Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes – Average fee amount –  $30 – $40

99402 – Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes $60 -$70

99403 – Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 45 minutes Average fee amount $80 -$100

99404 – Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 60 minutes -Average fee amount $110 -$130

Preventive Medicine Counseling Codes 99401, 99402, and 99211

If a member receives only immunization-related counseling during the visit, the provider may not bill a preventive medicine counseling code, and may only bill the vaccine administration fee. However, if the member receives other prevention counseling (besides the immunizations) such as child health, developmental milestones, sexually transmitted infection safety, etc., the provider may bill the following codes:

** 99401 – Approximately 15 minutes of counseling

** 99402 – Approximately 30 minutes of counseling

** 99211 – Approximately five (5) minutes of counseling (for examples, please see Appendix B – Clinical Examples in the AMA CPT billing manual)

** 99420 – administration and interpretation of a health risk assessment instrument – used for adolescent depression screening.

Keep documentation in the member’s chart that shows the duration of counseling and a list of the prevention topics covered during counseling.

CPT codes 99401–99404 (preventive medicine counseling, individual) are used for the purpose of promoting health and preventing illness or injury. They are not reported when counseling is related to a condition, disease, or treatment. These are time-based codes that require medical record documentation of the total time spent in counseling and a summary of the issues discussed. Codes 99401–99404 may be reported separately from other E/M services (eg, office visits, preventive medicine visits) when performed on the same day. Modifier 25 must be appended to codes 99401– 99404 to signify to the payer that the preventive medicine counseling was significant and separately identifiable from the preventive medicine or problem-oriented E/M visit.

Payment Policy  Overview

This policy describes Optum’s requirements for the reimbursement and documentation of “Obesity Screening and Counseling in Adults” – CPT codes 99401 and 99402, and HCPCS procedure code G0447.

The purpose of this policy is to ensure that Optum reimburses for services that are billed and documented, without  eimbursing for billing submission or data entry errors or for non-documented services.

Reimbursement Guidelines

For eligible health plan members with obesity, defined as Body Mass Index (BMI) equal to or greater than 30 kg/m2, Optum will align reimbursement with Medicare including:

° One face-to-face visit every week for the first month;

° One face-to-face visit every other week for months 2-6; and

° One face-to-face visit every month for months 7-12 [if the member meets the 3kg (6.6 lbs.) weight loss requirement during the first 6 months.]

For members who do not achieve a weight loss of at least 3 kg (6.6 pounds) during the first 6 months of intensive therapy, a reassessment of their readiness to change and BMI is appropriate after an additional 6-month period.

These visits must be provided by a qualified health care provider.

CPT codes for obesity screening and counseling are:

• 99401 – preventive medicine counseling and/or risk factor intervention/s provided to an individual (separate procedure); approximately 15 minutes

• 99402 – preventive medicine counseling and/or risk factor intervention/s provided to an individual (separate procedure); approximately 30 minutes HCPCS code for obesity screening and counseling is:

• G0447 – face-to-face behavioral counseling for obesity, 15 minutes – for billing for behavioral counseling for obesity

Billing and Coding Guidelines

Behavioral Counseling in Primary Care to Promote a Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults with Procedure Code(s): 97802 – 97804, 99401 – 99404, G0270, G0271, G0446, G0447, G0473, S9470, 0403T 97803

Diagnosis Code(s): SCREENING: 

• ICD-9: V77.91

• ICD-10: Z13.220

HISTORY:

• ICD-9: V15.82, V17.3, V17.49

• ICD-10: Z72.0, Z87.891, Z82.49, F17.210, F17.211, F17.213, F17.218, F17.219

Screening for Obesity in Adults

Procedure Code(s): 97802, 97803, 97804, 99401, 99402, 99403, 99404, G0446, G0447, G0473 (Also see codes in Wellness Examinations row above.) Diagnosis Code(s) (Required for 97802 – 97804 and 99401 – 99404): Body Mass Index 30.0 – 39.9:

• ICD-9: V85.30, V85.31, V85.32, V85.33, V85.34, V85.35, V85.36, V85.37, V85.38, V85.39

• ICD-10: Z68.30, Z68.31, Z68.32, Z68.33, Z68.34, Z68.35, Z68.36, Z68.37, Z68.38, Z68.39

Body Mass Index 40.0 and over:

• ICD-9: V85.41, V85.42, V85.43, V85.44, V85.45

• ICD-10: Z68.41, Z68.42, Z68.43, Z68.44, Z68.45

Obesity:

• ICD-9: 278.00, 278.01

• ICD-10: E66.01, E66.09, E66.1, E66.8, E66.9

Wellness Examinations (well baby, well child, well adult) Procedure Code(s): G0402, G0438, G0439, G0445, S0610, S0612, S0613, 99381 – 99387, 99391 – 99397, 99401 – 99404, 99411 – 99412, 99461, G0296 Diagnosis Code(s): n/a G0296 limited to age 55-80 years (ends on 81st birthday).

Providers should not bill for preventive medicine counseling if the session is less than 8 minutes in duration. Providers can bill for preventive medicine counseling (99401) of at least 8 minutes but less than 15 minutes in duration; however, they must add the “U5” modifier to the procedure line to indicate it is a “reduced service” which will result in the payment weight for the line being discounted by 30%. Note, the “U5” modifier should not be added to any other preventive  medicine service codes in the series (99402, 99403, and 99404).

In addition, insurance plans are permitted to impose cost-sharing (or choose not to provide coverage) for recommended preventive services if they are provided out-of-network. Not all services that some or many clinicians consider as preventive are included in the law. For preventive services not covered in the statute and regulations, plans are permitted to require cost-sharing. The new mandate may also affect payer coverage or payment policies for services listed in the Counseling Risk Factor Reduction and Behavior Change Intervention section of CPT (99401-99429)

HIV Counseling without Testing (excluding Preventive Care)

Report:

– CPT 99401-99404 based on total time spent counseling the patient

• HIV Post Test Counseling (Results Negative) Report:

– CPT 99401 to 99404 – OR – CPT 99211 to 99215

• HIV Post Test Counseling with Coordination of Care (Results Positive)

Report:

– CPT 99401 to 99404 – OR – CPT 99211 to 99215

Coding for preventive services

Correctly coding preventive care services is key to receiving accurate payment for those services. This video will give you guidelines.

• Preventive care services must be submitted with an ICD-9 code that represents encounters with health services that are not for the treatment of illness or injury. The ICD-9 code must be placed in the first diagnosis position of the claim form (see the list of designated “V codes” in the following table for each preventive service). This guide will include ICD-10 codes when updated in 2013.

• If claims for preventive care services are submitted with diagnosis codes that represent treatment of illness or injury as the primary (first) diagnosis on the claim, the service will not be identified as preventive care and your patients’ claims will be paid using their normal medical benefits rather than preventive care coverage.

• Use CPT coding designated as “Preventive Medicine Evaluation and Management Services” to differentiate preventive services from problem-oriented evaluation and management office visits (99381–99397, 99461, 99401–99404, S0610, S0612). Non-preventive care services incorrectly coded as “Preventive Medicine Evaluation and Management Services” will not be covered as preventive care.

› Submit the preventive care services with ICD-10 codes that represent health services encounters that are not for the treatment of illness or injury.

› Place the ICD-10 code in the first diagnosis position of the claim form (see the list of designated “Z codes” in the following table).

› Use CPT coding designated as “Preventive Medicine Evaluation and Management Services” to differentiate preventive services from problemoriented evaluation and management office visits (99381–99397, 99461, 99401–99404, S0610, S0612).

› Preventive care service claims submitted with diagnosis codes that represent treatment of illness or injury as the primary (first) diagnosis on the claim, will be paid as applicable under normal medical benefits rather than preventive care coverage.

› Nonpreventive care services incorrectly coded as “Preventive Medicine Evaluation and Management Services” will not be covered as preventive care.

› For reference purposes, this guide includes the ICD-9 codes that were effective for services provided prior to 10/01/2015. For services provided on or after 10/01/2015, ICD-10 codes must be used.

When a separately submitted service is inherently preventive, modifier 33 is not used.

• Routine immunizations recommended for persons living in the United States to prevent communicable diseases are inherently preventive. Therefore modifier 33 would not be appended to these codes.

• Preventive medicine services (office visit services) represented by codes 99381-99387, 99391-99397, 99401- 99404, and 99406-99412 are distinct from problem-oriented evaluation and management office visit codes and are inherently preventive. Therefore, modifier 33 would not be utilized with these codes.

• The CPT code for screening mammography is inherently preventive and therefore modifier 33 would not be used.

Did you know that you can get paid for doing the preventative care? You can.

In the CPT book it is called Counseling Risk Factor Reduction and Behavior Change Intervention.

This is a distinct set of codes from the traditional E and M services and can be billed IN addition to the E and M services you provide.

That means, no modifier 25.

The catch?

1. You have to document how much time you spend in preventative care. 99401 is 15 minutes of care.

2. You have to ICD9 code using a V code or a diagnosis code for the preventative care you are providing. Which means on Diagnosis Pointers on the HCFA form, you have to list a pointer.

3. You have to understand preventive medicine counseling and risk factor reduction interventions provided as a separate encounter will vary with age and should address such issues as family problems, diet and exercise, substance abuse, sexual practices, injury prevention, dental health and diagnostic and laboratory test results available at the time of the encounter.

What does this mean? It means that you get paid for performing preventative care. Something you should be doing just about every appointment.

Why not? If you are providing primary preventative care.

i.e. Use condoms, buckle up, adjust water temp, lift with your legs, lose weight

Then you should get paid for these additional preventative services.

The breakdown-

99401 is for 15 minutes of preventative care
99402 is for 30 minutes of preventative care
99403 is for 45 minutes of preventative care
99404 is for 60 minutes of preventative care

So, document what you do and then go ahead and bill for these important code. Remember, an ounce of prevention is worth a pound of cure and some insurers pay that way.

Preventive Care covered Services – BCBS


Benefits for Routine Exams and Immunizations

Benefits for routine exams are available for the following Preventive Care Services as indicated on your
Schedule of Coverage:

• well-baby care (after newborn’s initial examination and discharge from the Hospital);

• routine annual physical examination;

• annual vision examination;

• annual hearing examinations, except for benefits as provided under Required Benefits for Screening Tests for Hearing Impairment;

• immunizations. (Deductibles will not be applicable to immunizations of a Dependent child age seven years of age or younger.)

Benefits are not available for Inpatient Hospital Expense or Medical-Surgical Expense for routine physical examinations performed on an inpatient basis, except for the initial examination of a newborn child.

Injections for allergies are not considered immunizations under this benefit provision.

Benefits for Certain Tests for Detection of Human Papillomavirus and Cervical Cancer

Benefits are available for certain tests for the detection of Human Papillomavirus and Cervical Cancer, for each woman enrolled in the Plan who is 18 years of age or older, for an annual medically recognized diagnostic examination for the early detection of cervical cancer, as shown on your Schedule of Coverage. Coverage includes, at a minimum, a conventional Pap smear screening or a screening using liquid-based cytology methods as approved by the United States Food and Drug Administration alone or in combination with a test approved by the United States Food and Drug Administration for the detection of the human papillomavirus.

Reporting Evaluation and Management Services With Immunizations 

E/M services most often reported with the vaccine product and immunization administration include new and established patient preventive medicine visits (CPT codes 99381–99395), problem-oriented visits (99201–99215), and preventive medicine counseling services (99401–99404). Any of the aforementioned E/M codes can be reported as a single service or in combination when performed and documented on the same day of service by the same physician or physician of the same group and specialty.

The E/M service must be medically indicated, significant, and separately identifiable from the immunization administration.

• Payers may require modifier 25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to be appended to the E/M code to distinguish it from the administration of the vaccine.

• CPT code 99211 (established patient E/M, minimal level, not requiring physician presence) should not be reported when the patient encounter is for vaccination only because the Medicare Resource-Based Relative Value Scale (RBRVS) relative values for the immunization administration codes include administrative and clinical services (ie, greeting the patient, routine vital signs, obtaining a vaccine history, presenting the VIS and responding to routine vaccine  questions, preparation and administration of the vaccine, and documentation and observation of the patient following the administration of the  vaccine). However, if  the service is medically necessary, significant, and separately identifiable, it may be reported with modifier 25 appended to the E/M code (99211).

Note that the  medical record must clearly state the reason for the visit, brief history, physical examination, assessment and plan, and any other counseling or discussion items. The  progress note must be signed with the physician’s countersignature. For more information and clinical vignettes on the appropriate use of code 99211 during  immunization administration, visit www.aap.org/pubserv/codingforpeds for a copy of the AAP position paper on reporting 99211 with immunization administration. Payers  who do not follow the Medicare RBRVS may allow payment of code 99211 with immunization administration. Know your payer guidelines, and if payment is allowed, make  certain that the guidelines are in writing and maintained in your office. Be aware that a co-payment will be required when the “nurse” visit is reported.

• The same guidelines apply to physician visits (99201–99215). In other words, if a patient is seen for the administration of a vaccine only, it is not appropriate to report an E/M visit if it is not medically necessary, significant, and separately identifiable.

• If at the time of a preventive medicine visit a patient has a problem or abnormality that is addressed and requires significant additional work to perform the required key components, a problem-oriented E/M code (99201–99215) may be reported in addition to the preventive medicine services code. There should be separate documentation for the 2 services in the medical record. Typically the level of service is based on the level of history and medical decision-making that are performed and documented because the physical examination component is most often performed as part of the age-appropriate examination included in the preventive medicine service. Modifier 25 must be appended to the problemoriented E/M service to alert the payer that it was significant and separately identifiable. Each code is linked to the appropriate ICD-9-CM code.

CPT codes 99401–99404 (preventive medicine counseling, individual) are used for the purpose of promoting health and preventing illness or injury. They are not reported when counseling is related to a condition, disease, or treatment. These are time-based codes that require medical record documentation of the total time spent in counseling and a summary of the issues discussed. Codes 99401–99404 may be reported separately from other E/M services (eg, office visits, preventive medicine visits) when performed on the same day. Modifier 25 must be appended to codes 99401– 99404 to signify to the payer that the preventive medicine counseling was significant and separately identifiable from the preventive medicine or problem-oriented E/M visit.

• Remember that reviewing or discussing the risks and benefits of vaccines and addressing all other patient and parent concerns and questions related to vaccines and immunization administration are included in the immunization administration codes. However, if vaccine counseling is performed and the parent or patient refuses vaccines, the time spent in counseling may be separately reported. Also, if after additional time is spent in vaccine counseling, the parent or patient then decides to accept the immunizations and the time and effort exceeds that normally spent by the physician, it is still appropriate to report these codes in addition to the E/M visit and immunization administration. Make certain that the medical record supports the excess time and effort of counseling.

CPT Code ICD-9-CM Code

99381 Preventive medicine visit, new patient
V20.2
99401 25 Preventive medicine counseling V65.49 Other specified counseling
V15.83 Personal history of under-immunization status
V06.8
V04.89
V03.82
V64.05 Vaccination not carried out because of caregiver refusal

Teaching Point: Appending modifier 25 to code 99401 and reporting codes V15.83, V06.8, V04.89, V03.82 (need for inoculation against the specific diseases), and V64.05 advise the payer that the vaccine counseling was significant and separate from the preventive medicine visit, the child is behind on his or her immunizations, and the vaccines were refused.

6. A 6-month-old returns for her second hepatitis B vaccine. She did not receive the vaccine during her preventive medicine visit because she was ill. The nurse has documented the following: The patient is here for a missed hepatitis vaccine. Afebrile for 5 days, eating well. Temperature is 98.7°F; active and playful. The risk and potential side effects of the hepatitis vaccine were discussed after the VIS was given and the parent was informed of the correct dosage of an antipyretic medication should fever or fussiness occur afterward.