CPT Codes for Counseling (Primary Care)

If you do not have an account: This page is part of a larger Buprenorphine training activity provided by Clinical Tools, Inc. Our DATA 2000/CARA-qualifying Buprenorphine training provides the current information for physicians, nurse practitioners, and physician assistants on prescribing buprenorphine as an office-based treatment for opioid use disorder. Please refer to the Buppractice.com homepage to sign-up and begin the activity!

Current accounts: If you see this message, the system has logged you out because of inactivity. To resume:

  1. Log In
  2. Go To Activity Homepage (Module list page)
  3. Re-Enter Module To Resume Training
Counseling and Coordinating with Addiction Specialists

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).

Documenting a Counseling Visit

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