Please help! E/M Counseling Codes

[klovemeister@hotmail.com]

Hello!
I recently started working in a public health office. We are conducting an audit and I have been asked to confirm the following:
The new patient is a 21 year old female seen for a general adult exam and contraceptive management. Total face to face was 50 and >50 minutes was spent on counseling. This was originally coded as a 99385 but I am being asked if we can ALSO bill code 99402. My experience is more in surgical coding rather than E/M and could use some assistance. I see that code 99385 includes counseling, but does not specify a time limit, which is where my doubt/confusion comes in. Please help and thank you in advance!

 

[CodingKing]

Routine physicals are not time specific. The age appropriate counseling would be inclusive in the 99385. 99402 is more for preventive counseling in same visit as a sick visit. It would be double dipping.

CPT manual states the following

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Codes 99381-99397 include counseling/anticipatory guidance/risk factor reduction interventions which are provided at the time of the initial or periodic comprehensive preventive medicine examination. (Refer to codes 99401-99412 for reporting those counseling/anticipatory guidance/risk factor reduction interventions that are provided at an encounter separate from the preventive medicine examination.)

 

[klovemeister@hotmail.com]

Thank you so much!!