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.