Pediatric Coding Alert

Question: When we billed CPT® codes 99395-25 (Periodic comprehensive preventive medicine reevaluation and management) and 99401 together, the insurance paid us for 99395-25 but denied 99401 as “procedure not payable when performed with other related procedures on the same date of service.” We used an ICD-9 code v70.0 (General medical examination) on 99395-25 and ICD-9 code V65.40 (Counseling NOS) on 99401. Was this denied correctly?

Answer: The 99401-99404 series (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]; approximately 15 minutes) is for risk reduction (anticipatory counseling), which most payers consider to be already included in the preventive medicine codes. Therefore, the insurer was most likely denying your claim appropriately.

When these codes were originally valued, they included 15 minutes of preventive medicine counseling. If you ever do happen to encounter 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-9 diagnostic code. This problem E/M code should have a modifier 25 attached, signifying a significant, separate E/M service from the preventive medicine visit.