Pediatric Coding Alert

Reader Question:

Risk Factor, Primary Illness Determine Group Session Coding

Question: Our office has set up a group for several new mothers and their babies that will meet for about an hour a week. Should we code this as four units of 96153 (Health and behavior intervention, each 15 minutes, face-to-face; group [2 or more patients]) or one unit of 99412 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to individuals in a group setting [separate procedure]; approximately 60 minutes).

Texas Subscriber

Answer: The descriptors for 96152-96155 are very specific regarding the number of people who may participate in the intervention:

  • 96152, … face-to-face; individual
  • 96153, … group (2 or more patients)
  • 96154, … family (with the patient present)
  • 96155, … family (without the patient present)

So, 96153 x 4 would appear to be a good choice for coding such a group session.

However, CPT® guidelines specify that 96152-96155 are “services offered to patients who present with primary illnesses, diagnoses or symptoms.” The guidelines go on to say that the services “do not represent preventive medicine counseling and risk factor reduction interventions.”

It is these risk factor reduction interventions that mark the main difference between 996152-96155 and 99412. Spe­cifically, CPT® defines risk factor reduction interventions should be used “for persons without a specific illness for which counseling might other be used as part of treatment.”

You do not mention whether your group has a problem focus. If all the babies suffered from a similar condition — if they were all premature, for example, or suffered from fetal alcohol syndrome — then 96153 would be the best way to code the sessions. But if this is a support group for mothers and babies that focuses on the kind of day-to-day issues that all new parents and their children face, then 99412 would be the most accurate code to use for the encounter.

Also, the 96152-96155 codes are not for physicians; only for your practice’s nonphysician healthcare providers.

Coding tip: Whichever code you choose, however, make sure you follow the CPT® guidelines and do not report health and behavior assessment/intervention services (96150-96155) with evaluation and management (E/M) services on the same day. This includes counseling and risk factor reduction and behavior change intervention services (99401-99412).