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Documentation for pediatric counseling

  1. #1
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    Adirondack Chapter of Professional Coders, Glens Falls, NY
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    I have a pediatric provider who provides diet, nutrition, exercise, wellness, etc. education in a group setting. She has mostly been billing these visits as 99078. Does anyone know what the documentation requirements are for this code? Is time a factor at all? Any information would be most helpful!

  2. #2
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    Quote Originally Posted by jhartung View Post
    I have a pediatric provider who provides diet, nutrition, exercise, wellness, etc. education in a group setting. She has mostly been billing these visits as 99078. Does anyone know what the documentation requirements are for this code? Is time a factor at all? Any information would be most helpful!
    Hi. I would suggest codes 99411 or 99412 for preventive counseling in a group session if the services are truly preventive. However, there's CPT instructional info saying to use 99078 for group counseling of patients with symptoms or established illnesses.

    Codes 99411 and 99412 are timed-based (30 and 60 minutes, respectively) so time documentation with these codes is pretty much a given. It's probably a good idea to include documentation of the number of patients in the group and what counseling was provided, as well as investigating coverage from your payers.

    The American Academy of Pediatrics has all kinds of coding and documentation information, so if your provider is an AAP member, perhaps she can share her access to that information with you.

    Hope this helps,
    Jettman

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