Wiki Counseling and Coordination of Care


Local Chapter Officer
Middle town, NY
Best answers
In the Edge Blast #123 - Question # 3 I beg to differ:
Answer should be 99213, 99401 as opposed to 99212, 99401.

15 minutes of time spent counseling the patient constitutes more than 50% of the E&M and time becomes the key factor. That is, 15 minutes out of 25 minutes (99212 - 10 minutes) is spent counseling. 99401 - 99405 are non-reimbursable services for Medicare. Physician documentation support Total time : 25 minutes; Time Spent counseling 15 minutes; and Topic of Counseling: Preventive Medicine for patient at high risk of Breast Cancer.

Based on the AMA CPT 2009 Edition, the E&M should not have been based on problem focused history and exam, but on time as the key factor of the E&M of 15 minutes. Time of 15 minutes is a 99213. Should we count 25 minutes as Times? Also, since Medicare doesn't pay for a 99401, it is only provided to acknowledge the amount of time spent in the session counseling.

Please explain why this may be incorrect or what is the purpose of the counseling code (99401) if it doesn't enhance the E&M code (i.e., reimbursement)?

Eddie Hearns MA, CPC-I
Last edited:
In coding, you should never make assumptions! You have to work with the information available (documented). How did you conclude that the 15 minutes are part of a 25 minutes visit? Where are those 25 minutes documented? Just because history and exam code out to problem focused each does not mean that it actually took 10 minutes to arrive there. Also, Medicare does not cover preventative visits (with some very specific exceptions). You can charge Medicare only for the component of the visit that is billable. If the scenario were something like: "Dr. X spent 15 minutes with Pt. Y, of which 10 were counseling regarding ..... (ongoing issues, e.g., diabetes) and an additional 15 minutes of preventive counseling for the high risk of breast CA." then I would bill 99213, 99401. You cannot count the part spent on preventative care towards the office visit code.
Hope this makes it a bit clearer.
3) A gynecologist provides 15 minutes of preventive counseling to an established Medicare patient at high risk for breast cancer during an office visit that involved a problem focused history and exam. How do you code the service?

Eddie - the "15 minutes" they're referring to IN THIS SCENARIO is "preventive counseling"..... this 15 minutes was service provided to that patient -'preventive service' --ABOVE and BEYOND the "problem focused history/ exam" (which is a level 2 - 99212).
Given that info - the E/M is a 99212 - and the 99401 is for the "added 15 minutes of preventive counseling" for this Medicare patient.

The example does not support "coding based on time"... there's no mention of total time spent, no mention of "more than 50% of time dominating counseling/coordination of care". It simply tells us two things,...
1) they had a problem focused History & Exam (which makes it a 99212)
2) they spent 15 minutes (extra) providing preventive counseling.
so not only are you looking for "two codes"...but it tells you the first code based on the info given (PF history/exam).

the answer is B.

did that help at all, or just throw more mud on the picture? ;)