American College of Physicians: Internal Medicine — Doctors for Adults ®


Counseling patients with diabetes? Here's how to bill

From the November ACP Observer, copyright 2004 by the American College of Physicians.

By Brett Baker

With the number of patients with diabetes on the rise, internists are placing a growing emphasis on preventive and counseling services for diabetic patients.

This is the second of a two-part series on how internists should bill and code for treating patients with diabetes, which already affects more than 14 million Americans.

This month's column will focus on counseling and preventive evaluation and management (E/M) services, while last month's column discussed billing and coding for E/M services based on history, exam and medical decision-making. (See "How should you bill and code for patients with diabetes?" in the October ACP Observer. Billing and coding tips for laboratory tests needed for diabetic patients are also online.

While this information is based on Medicare regulations, keep in mind that most health plans base their own billing and coding requirements on Medicare rules. Check with your local insurers to see if they follow Medicare requirements or have different ones of their own.

Q: What is considered counseling, and what are the first steps to obtaining reimbursement?

A: According to the Current Procedural Terminology (CPT) definition, counseling is a discussion with a patient and/or patient's family that concerns one or more of the following:

  • diagnostic results, impressions and/or recommended diagnostic studies;

  • prognosis;

  • risks and benefits of management (treatment) options;

  • instructions for management (treatment) and/or follow-up;

  • importance of compliance with chosen management (treatment) options;

  • risk factor reduction; and

  • patient and family education.

Physician counseling could include smoking cessation, nutrition or weight advice related to disease, illness or injury.

To bill for physician counseling, choose an appropriate E/M service code. The CPT descriptors for E/M service levels recognize seven components, six of which are used to define those levels. Components include:

  • history;

  • exam;

  • medical decision-making;

  • counseling;

  • coordination of care;

  • nature of presenting problem; and

  • time.

History, exam and medical decision-making are the key factors in selecting a level of E/M service. Counseling, coordination of care and nature of the presenting problem, on the other hand, are contributory factors; that means they are important but not necessary to provide at every patient encounter. Time is included as a factor to help physicians select the most appropriate level of E/M service, with a "typical time" assigned to most E/M service codes.

In selecting an appropriate service level, you can use time as the determining factor when counseling and/or coordination of care accounts for more than half of the face-to-face time spent with a Medicare patient.

If smoking cessation and/or proper nutrition instruction dominates the encounter, code according to total face-to-face time regardless of your level of history, exam and decision-making. That's because counseling and/or coordination of care accounted for more than half the visit.

You would, for example, select CPT 99214 if you spent 20 minutes of a 30-minute in-office encounter counseling an established patient regarding smoking cessation. Why? Because the 30-minute encounter exceeds the "typical time" of 25 minutes for that code, but fell short of the 40-minute typical time for CPT code 99215.

Remember to document in the medical record the total face-to-face time with the beneficiary and the specific amount of that time spent on counseling and/or coordination of care.

Q: How do I bill for medically necessary counseling furnished in my office by a nonphysician health professional?

A: A physician can bill for counseling that a staff nurse or other auxiliary office personnel provides to a patient without direct physician involvement by using CPT 99211. That code is for services that do not require a physician's presence.

A physician can bill for counseling provided by a mid-level practitioner—such as a nurse practitioner, physician assistant or clinical nurse specialist—acting as a surrogate for the physician using CPT 99211-99215, as long as that counseling meets Medicare's "incident-to" criteria. Those are:

  • Physicians perform the initial E/M service and subsequent services that reflect their active participation in the beneficiary's treatment; and

  • Physicians provide direct personal supervision of the nonphysician provider, are in the same suite (but not necessarily in the same exam room), and are immediately available to give assistance and direction.

Medicare will pay 100% of the fee listed on the physician fee schedule if these incident-to criteria are met.

If, however, the E/M service fails to meet these criteria because the nonphysician provides an E/M service or counseling to a new patient, or does so without direct personal supervision from a physician, you should bill for the service using the nonphysician's identification number. For these types of counseling encounters, Medicare will pay 85% of the fee listed on the fee schedule.

Q: How do I code and bill for preventive E/M services?

A: For preventive services provided at visits for new and established patients, use the preventive medicine service new and established patient visit codes, CPT 99381-99397. For these codes, you need to report an age- and gender-appropriate history; exam; interventions for counseling, anticipatory guidance and risk factor reduction; and any orders involving appropriate immunization, laboratory and diagnostic procedures.

Medicare will not pay for these services because the law prohibits coverage for a comprehensive preventive exam. You can charge patients your usual fee for these services—but let patients know before you furnish the service that you will be billing them directly.

For preventive medicine service counseling and/or risk factor reduction interventions, report counseling provided to asymptomatic beneficiaries using the preventive medicine services counseling and/or risk factor reduction codes, CPT 99401-99412.

These codes, which describe services that promote health and prevent illness or injury, represent services that the law does not allow Medicare to cover. Again, you can charge patients your usual fee for these services.

Brett Baker is a third-party specialist in the College's Washington office.


This is a printer-friendly version of this page

Print this page  |  Close the preview




Internist Archives Quick Links

Not an ACP Member?

Join today and discover the benefits waiting for you.

Not an ACP Member? Join today and discover the benefits waiting for you

ACP offers different categories of membership depending on your career stage and professional status. View options, pricing and benefits.

A New Way to Ace the Boards!

A New Way to Ace the Boards!

Ensure you're board-exam ready with ACP's Board Prep Ace - a multifaceted, self-study program that prepares you to pass the ABIM Certification Exam in internal medicine. Learn more.