Coding a Follow-Up Visit that Turns Into a Counseling Session

Patients don’t always stick to the sole reason for their medical visit. Especially pediatric visits. A good scenario that is not too uncommon is when a mother brings in her son for a follow up visit to determine if his ear infection (otitis media) has subsided with the antibiotic regiment that was prescribed.

However during the recheck she has questions about some behavior she is seeing in her son that leads her to believe he may be ADD (attention deficit disorder) and the physician has a counseling session with her that discusses options and risks involved, possibility of medications and other forms of treatment that takes about 25 minutes. The recheck only took about 10 minutes so the patient’s visit lasts a total of 35 minutes.

The easiest way to code this to ensure reimbursement would be to use 99214. If the visit had been comprised of only the otitis media recheck, in which no problems were found, the encounter for a previous problem alone would probably qualify as 99212 or 99213 (Office or other outpatient visit for the evaluation and management of an established patient …). Choose the level based on the documentation that meets the required elements (two of three key components).

The discussion that followed the recheck took an additional 25 minutes of time. Because the discussion comprised 50 percent or more of the total face-to-face time of the visit, you should use time as the controlling factor to select the level of service. A total of 35 face-to-face minutes exceeds the approximate time that CPT designates for a level-four established patient visit (99214, … physicians typically spend 25 minutes face-to-face with the patient and/or family). Important: The time spent does not meet the time threshold for 99215, which requires 40 minutes.

Remember that documentation is critical. The accurate detailed reporting of total face-to-face time and time spent counseling is critical. If documentation shows the exact amount of time spent in discussion and what was discussed as you described above, you should report the encounter with 99214.

View all Articles by: Kathryn Etienne, CCS-P