CPT Codes for Counseling (Primary Care)
A large portion of maintenance visits consist of counseling and coordinating service with addiction specialists. You can provide counseling and bill for it without conducting a review of systems. In this case, you should use Counseling codes in place of E/M codes (99211-15).
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
You can bill for counseling time rather than complexity in a visit when counseling or coordination of care take up more than 50% 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 _____."
|Level||New Patient Counseling||Established Patient Counseling|
|1||10-19 minutes: 99201||5-9 minutes: 99211|
|2||20-29 minutes: 99202||10-14 minutes: 99212|
|3||30-44 minutes: 99203||15-24 minutes: 99213|
|4||45-59 minutes: 99204||25-39 minutes: 99214|
|5||60+ minutes: 99205||40+ minutes: 99215|