Commonly Used CPT Codes for Counseling - Primary Care

Counseling and coordinating service with addiction specialists will be a large portion of maintenance visits. PCPs can provide and bill for counseling without conducting a review of systems, and should use Counseling codes in place of E/M codes (92211-15). Documentation for a counseling visit should include:

• Total visit time
• Time spent counseling or coordinating care (must be face-to-face)
• The nature/content of the counseling

The determining factor for when PCPs can use counseling time rather than complexity in a visit is that counseling or coordination of care must take up more than 50% of of the total visit time. Coding is then based on the total visit time, not just the time spent counseling or coordinating care. A statement such as the following serves as documentation of time spent:

"A total of ___ minutes of a _____ minute visit was spent counseling the patient about _____. "