Pediatric Coding Alert

Question: I am looking for CPT^® or HCPCS codes for health coach services that would be billable to an insurance carrier. What would you recommend?

Colorado Subscriber

Answer: It’s difficult to pinpoint the best code without knowing what you mean by “health coach.” There are no codes in CPT^® or HCPCS that specifically reference health coaching. Here are several sets of codes to consider, depending on the exact service(s) your provider is offering:

·         Codes 99381-99387 (Initial comprehensive preventive medicine evaluation and management of an individual …) or 99391-99397 (Periodic comprehensive preventive medicine reevaluation and management of an individual …): These codes represent preventive medicine evaluation and management services for new and established patients. They include an age and gender appropriate medical history and exam, as well as counseling/anticipatory guidance/risk factor reduction interventions and the ordering of appropriate laboratory/diagnostic procedures.

·         Codes 99401-99404 (Preventive medicine counseling …):  These essentially involve the preventive medicine counseling and/or risk factor reduction interventions referenced above without the corresponding history and exam.

·         Codes 99487-99489 (Complex chronic care coordination services …): These are new for 2013 and represent the work involved in various activities coordinating the patient’s care during the course of a month. The codes are used for patients who have multiple chronic conditions and might be seeing several providers from different specialties on a regular basis. CPT^® 2013 includes comprehensive instructions in its guidelines for when and how to report these codes.

·         Codes 96150 (Health and behavior assessment…) and 96155 (Health and behavior intervention…) — These codes relate to health interventions that don’t include mental health issues.

·         Code 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician…) if employees such as RNs and medical assistants perform the “health coach” services.

If nothing else seems to fit, you might have to report 99499 (Unlisted evaluation and management service) with thorough documentation of the services. This will be questioned by the payer and will require submission of supporting documentation.

Before submitting a claim, be sure you have a good understanding of what your provider is doing as a “health coach.” Also ensure that the individual who is serving as a “health coach” is otherwise eligible to bill for his or her services as a provider with the payer. Then, if the codes listed above don’t seem to apply, talk with your payer representative for suggestions.