Pediatric Coding Alert


Bust These Myths for Clear Contraceptive Service Coding

Experts weigh in on ways to report counseling, procedures.

Providing contraceptive services is one of the most significant — and most misunderstood — ways your pediatrician can aid your adolescent female patients. Knowing when you should code the encounter as a periodic preventive service or a risk factor intervention, for example, can be a real problem.

So, too, can understanding when the encounter should be coded as a straight evaluation and management (E/M) service. And knowing when, and when not, to code for procedures, creates its own separate set of issues.

So, we rounded up four common myths about coding for these encounters to help you separate the fact from the fiction surrounding the correct coding choices for contraception services.

Myth 1: When a Patient Requests Contraceptive Services, You Should Code for a Preventive Service Visit.

For many adolescent female patients, contraceptive discussion without a procedure is typically performed during a preventive medicine service exam,” says Sherika Charles, CDIP, CCS, CPC, CPMA, compliance analyst with UT Southwestern Medical Center in Dallas, Texas. This means you would report 99384/99394 (Initial/Periodic comprehensive preventive medicine evaluation and management of an individual …; adolescent (age 12 through 17 years) or 99394/99395 (… 18-39 years), bearing in mind that “the discussion is not reported separately from the preventive service visit,” according to Charles.

However, “if it is a standalone service, the counseling should be reported under the Preventive Medicine Counseling Service codes,” Charles advises. So, if a patient comes to your pediatrician and requests counseling prior to receiving contraceptive services, and “if only counseling is performed with development of a contraceptive plan, the coding would be 99401-99404 [Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual …],” says Jan Rasmussen, PCS, CPC, ACS-GI, ACS-OB, owner/consultant of Professional Coding Solutions in Holcombe, Wisconsin.

The exact code would be “based on time spent face-to-face,” Rasmussen reminds coders. But, “many insurances may not cover 99401-99404 preventive counseling,” so it is important that you check with your payer beforehand, Rasmussen cautions.

Myth 2: During a Preventive Service Visit, You’ll Use 99401-99404 for the Counseling.

The confusion over this myth seems to stem from the wording of the descriptors. Because 99401-99404 contain the words “preventive medicine,” it is tempting to see them as additional codes for 99381-99397. But, “preventive services 99381-99397 include counseling, which may not be separately billed,” Rasmussen tells coders. This agrees with the CPT® guidelines, which note that “Codes99381-99397include counseling/anticipatory guidance/risk factor reduction interventions which are provided at the time of the initial or periodic comprehensive preventive medicine examination.”

CPT® guidelines go on to say that, as we saw in Myth 1, the risk factor reduction codes are only appropriate for encounters “separate from the preventive medicine examination.”  

Myth 3: Contraceptive Services for Medical Reasons Are Billed the Same Way as Contraceptive Services for Preventing Pregnancy.

While “contraceptive services for preventing pregnancy would be billed as either a preventive medicine service exam or counseling if it is a standalone issue, if the contraceptive service is due to medical reasons, it may be reported with the appropriate office visit code,” says Charles.

“Contraceptive treatment for a medical problem would be billed as a problem-oriented service,” Rasmussen agrees. So, if your pediatrician prescribes contraception for medical reasons, (for example, prescribing birth control pills for conditions such as amenorrhea [N91.-] or endometriosis [N80.-]), you can no longer code the service using 99381–99385 or 99391–99395. In this situation, you will now have to choose the appropriate E/M service from 99201-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …).

Myth 4: You Cannot Bill Injectable Contraceptives and IUDs Separately from Counseling Services.

In fact, you can bill both forms of contraception separately. So, if your pediatrician administers Depo-Provera to your patient, you can go ahead and bill J1050 (Injection, medroxyprogesterone acetate, 1 mg) for the supply along with 96372 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular) for the injection itself.

And if your provider opts for insertion for one of the following intrauterine devices…

  • J7297 — Levonorgestrel-releasing intrauterine contraceptive system (liletta), 52 mg
  • J7298 — Levonorgestrel-releasing intrauterine contraceptive system (mirena), 52 mg
  • J7301 — Levonorgestrel-releasing intrauterine contraceptive system (skyla), 13.5 mg
  • J7300 — Intrauterine copper contraceptive

… then you’ll be able to bill for the supply along with 58300 (Insertion of intrauterine device (IUD)) for the service.