Commonly Used CPT Codes for Counseling - Primary Care

Counseling and coordinating service with addiction specialists will be a large portion of maintenance visits. Waivered providers can provide and bill for counseling without conducting a review of systems, and 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

The determining factor for when to 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 _____. "

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

*Note: All 5 levels are included in this table, however, level 5 is infrequently used in primary care and typically involves problems of moderate to high severity.