{"id":10647,"date":"2020-03-09T16:32:41","date_gmt":"2020-03-09T11:02:41","guid":{"rendered":"https:\/\/www.medicalbillersandcoders.com\/blog\/?p=10647"},"modified":"2024-10-06T15:39:23","modified_gmt":"2024-10-06T15:39:23","slug":"coding-for-opioid-use-and-counseling","status":"publish","type":"post","link":"https:\/\/www.medicalbillersandcoders.com\/blog\/coding-for-opioid-use-and-counseling\/","title":{"rendered":"Coding for Opioid Use and Counseling"},"content":{"rendered":"<p style=\"text-align: left;\">For any case of pregnancy in which a woman uses opioids during the pregnancy or postpartum period, codes from subcategory O99.32, Drug use complicating pregnancy, childbirth, and the puerperium, should be assigned. A secondary code from category F11, Opioid-related disorders, should also be assigned to identify the manifestation of Opioid Use and Counseling.<\/p>\n<h2 style=\"text-align: left;\">Opioid Use and Counseling:<\/h2>\n<p style=\"text-align: left;\">\u2022 O99.320 Drug use complicating pregnancy, unspecified trimester<br \/>\n\u2022 O99.321 Drug use complicating pregnancy, first trimester<br \/>\n\u2022 O99.322 Drug use complicating pregnancy, second trimester<br \/>\n\u2022 O99.323 Drug use complicating pregnancy, third trimester<br \/>\n\u2022 O99.324 Drug use complicating childbirth<br \/>\n\u2022 O99.325 Drug use complicating the puerperium<br \/>\n\u2022 F11.10 Opioid abuse, uncomplicated<br \/>\n\u2022 F11.11 Opioid abuse, in remission<br \/>\n\u2022 F11.12 Opioid abuse with intoxication<br \/>\n\u2022 F11.14 Opioid abuse with an opioid-induced mood disorder<br \/>\n\u2022 F11.15 Opioid abuse with an opioid-induced psychotic disorder<br \/>\n\u2022 F11.18 Opioid abuse with other opioid-induced disorder<br \/>\n\u2022 F11.19 Opioid abuse with an unspecified opioid-induced disorder<br \/>\n\u2022 F11.2 Opioid dependence<br \/>\n\u2022 F11.9 Opioid use, unspecified<\/p>\n<h2 style=\"text-align: left;\">Counseling<\/h2>\n<p style=\"text-align: left;\">Procedure codes such as Evaluation and Management (E\/M) codes are a method of documenting what service or procedure was performed. The most appropriate E\/M code to select will depend on whether the encounter was for screening or treatment of the condition.<\/p>\n<p style=\"text-align: left;\">If the encounter was for screening the patient, report a preventive medicine code. These codes are selected according to the time spent in face-to-face counseling with the patient. Whether or not these codes will be reimbursed will vary.<\/p>\n<h3 style=\"text-align: left;\">Possible procedure codes are the following:<\/h3>\n<ul>\n<li style=\"text-align: left;\">99401\u201399404 Preventive medicine, individual counseling<\/li>\n<li style=\"text-align: left;\">99411\u201399412 Preventive medicine, group counseling<\/li>\n<\/ul>\n<p style=\"text-align: left;\"><strong>Specific CPT codes have been developed for tobacco cessation counseling. These services are reported as follows:<\/strong><\/p>\n<ul style=\"text-align: left;\">\n<li>99406 Preventive medicine, Smoking\/tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes<\/li>\n<li>99407 Preventive medicine, Smoking\/tobacco use cessation counseling visit; intensive, greater than 10 minutes<\/li>\n<\/ul>\n<p style=\"text-align: left;\">For counseling groups of patients with symptoms or established illnesses, use CPT code 99078.<\/p>\n<p style=\"text-align: left;\">If the encounter was for other treatment for a patient with a diagnosis of tobacco use or nicotine dependence, report an office or other <a href=\"https:\/\/www.aapc.com\/evaluation-management\/em-coding-outpatient-services.aspx\">outpatient E\/M code<\/a>.<\/p>\n<p style=\"text-align: left;\">These codes list a \u201ctypical time\u201d in the code descriptions. Codes with typical times listed may be reported based on time, rather than the key E\/M components of history, examination, and <a href=\"https:\/\/www.medicalbillersandcoders.com\/\">medical decision-making<\/a>.<\/p>\n<p style=\"text-align: left;\">If the health care provider spends more than 50% of the visit counseling the patient, the E\/M code may be selected based on time. Time spent providing face-to-face counseling with the patient must be documented in the medical record.<\/p>\n<p style=\"text-align: left;\">The record should document the total time and that either all of the encounters or more than 50% of the total time was spent counseling the patient. The patient record also must provide details on the topics discussed.<\/p>\n<h2 style=\"text-align: left;\">FAQs:<\/h2>\n<h3 style=\"text-align: left;\">1. What codes should be assigned for opioid use during pregnancy?<\/h3>\n<p style=\"text-align: left;\">For opioid use during pregnancy, assign codes from subcategory O99.32 and a secondary code from category F11 for opioid-related disorders.<\/p>\n<h3 style=\"text-align: left;\">2. What are the specific O99.32 codes?<\/h3>\n<p style=\"text-align: left;\">The O99.32 codes include options for different trimesters, childbirth, and the puerperium, like O99.320 for unspecified trimester and O99.323 for the third trimester.<\/p>\n<h3 style=\"text-align: left;\">3. How are counseling services documented?<\/h3>\n<p style=\"text-align: left;\">Counseling services can be documented using E\/M codes, depending on whether the visit was for screening or treatment, based on time spent with the patient.<\/p>\n<h3 style=\"text-align: left;\">4. What CPT codes are available for tobacco cessation counseling?<\/h3>\n<p style=\"text-align: left;\">CPT codes 99406 and 99407 are used for intermediate and intensive tobacco cessation counseling, respectively, based on the duration of the visit.<\/p>\n<h3 style=\"text-align: left;\">5. How is time spent on counseling recorded for E\/M codes?<\/h3>\n<p style=\"text-align: left;\">If more than 50% of the visit is spent counseling, it must be documented in the medical record, noting the total time and topics discussed.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>For any case of pregnancy in which a woman uses opioids during the pregnancy or postpartum period, codes from subcategory O99.32, Drug use complicating pregnancy, childbirth, and the puerperium, should be assigned. A secondary code from category F11, Opioid-related disorders, should also be assigned to identify the manifestation of Opioid Use and Counseling. Opioid Use [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":10649,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[434],"tags":[697,746,80,747,359,737,738,46,47,750,751,964,83,15,417,162,724,9,11,64,16,339,146,192,753,150,754,1180,1056,1181,1059,418,144,815,816,58,34,27,763],"class_list":["post-10647","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-ob-gyn-billing-services","tag-accounts-receviables-audits","tag-billing-services-for-doctors","tag-cpt-codes","tag-cpthcpcs","tag-dme-billing-services","tag-e-m-codes","tag-e-m-services","tag-ehr","tag-emr-ehr-health-it","tag-general-surgery-billing","tag-hcpcs-code","tag-icd-10-codes-for-ob-gyn","tag-icd-10-training","tag-medical-billing","tag-medical-billing-agencies","tag-medical-billing-and-coding-services","tag-medical-billing-audit","tag-medical-billing-companies","tag-medical-billing-outsourcing","tag-medical-billing-practices","tag-medical-billing-service","tag-medical-coding-audits","tag-medicare-2","tag-medicare-medicaid-services","tag-medicare-billing","tag-medicare-claims","tag-modifier","tag-ob-gyn-billing-and-coding","tag-ob-gyn-billing-providers","tag-ob-gyn-coding-guidelines","tag-ob-gyn-coding-services","tag-online-medical-billing","tag-outsource-medical-billing","tag-outsourced-medical-billing-company","tag-outsourced-medical-billing-services","tag-rcm","tag-reimbursement","tag-revenue-cycle-management-2","tag-wound-care-billing-services"],"yoast_head":"<!-- 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