How To Use CPT Code 99403

CPT 99403 refers to preventive medicine counseling and/or risk factor reduction intervention provided to an individual for approximately 45 minutes. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 99403.

1. What is CPT 99403?

CPT 99403 is a medical billing code used to describe preventive medicine counseling and/or risk factor reduction intervention services provided to an individual patient. This code is specifically used for sessions that last approximately 45 minutes. The purpose of these counseling sessions is to educate and guide patients on how to prevent potential health problems and reduce risky behaviors based on their age, family history, and other relevant factors.

2. 99403 CPT code description

The official description of CPT code 99403 is: “Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 45 minutes.”

3. Procedure

The 99403 CPT code procedure involves the following steps:

1. The healthcare provider reviews the patient’s medical history, lab results, and clinical findings from recent preventive visits.
2. Based on the patient’s age, family history, and other relevant factors, the provider identifies potential health risks and areas of concern.
3. The provider discusses with the patient various preventive measures and risk reduction strategies tailored to their specific needs and circumstances.
4. The provider may provide educational materials, resources, or referrals to support the patient’s efforts in implementing the recommended preventive measures and risk reduction strategies.
5. The session lasts approximately 45 minutes.

4. Qualifying circumstances

Patients eligible to receive CPT code 99403 services include those who:

• Have a documented need for preventive medicine counseling and/or risk factor reduction intervention based on their age, family history, or other relevant factors.
• Are able to actively participate in a 45-minute counseling session.
• Have not received similar counseling services within a specific time frame, as determined by the healthcare provider and/or payer guidelines.
• Are not receiving these services as part of a separate preventive medicine visit or evaluation and management service.

5. When to use CPT code 99403

It is appropriate to bill the 99403 CPT code when:

• The healthcare provider has conducted a separate preventive medicine visit and identified the need for additional counseling and/or risk factor reduction intervention.
• The patient meets the qualifying circumstances outlined above.
• The counseling session lasts approximately 45 minutes.
• The healthcare provider has documented the necessary information to support the claim, as outlined in the documentation requirements section below.

6. Documentation requirements

To support a claim for CPT 99403, healthcare providers must document the following information:

• The patient’s age, family history, and other relevant factors that justify the need for preventive medicine counseling and/or risk factor reduction intervention.
• A detailed description of the topics discussed during the counseling session, including specific preventive measures and risk reduction strategies recommended to the patient.
• The duration of the counseling session (approximately 45 minutes).
• Any educational materials, resources, or referrals provided to the patient during the session.
• A statement indicating that the counseling session was separate from any other preventive medicine visit or evaluation and management service.

7. Billing guidelines

When billing for CPT code 99403, healthcare providers should keep in mind the following guidelines and tips:

• Ensure that the patient meets the qualifying circumstances for receiving CPT 99403 services.
• Document the required information to support the claim, as outlined in the documentation requirements section above.
• Verify payer-specific guidelines and requirements for billing CPT 99403, as some payers may have additional criteria or restrictions.
• Consider using modifier 25 when billing CPT 99403 in conjunction with an evaluation and management service on the same day, to indicate that the counseling session was a separate and distinct service.

8. Historical information

CPT 99403 was added to the Current Procedural Terminology system on January 1, 1992. There have been no significant updates to the code since its addition.

9. Similar codes to CPT 99403

Five similar codes to CPT 99403 include:

• CPT 99401: This code is used for preventive medicine counseling sessions lasting approximately 15 minutes.
• CPT 99402: This code is used for preventive medicine counseling sessions lasting approximately 30 minutes.
• CPT 99404: This code is used for preventive medicine counseling sessions lasting approximately 60 minutes.
• CPT 99411: This code is used for group preventive medicine counseling sessions lasting approximately 30 minutes.
• CPT 99412: This code is used for group preventive medicine counseling sessions lasting approximately 60 minutes.

10. Examples

Here are 10 detailed examples of CPT code 99403 procedures:

1. A 45-year-old patient with a family history of heart disease receives a 45-minute counseling session on heart-healthy nutrition, exercise, and stress management.
2. A 30-year-old patient with a recent diagnosis of prediabetes receives a 45-minute counseling session on blood sugar monitoring, dietary changes, and physical activity recommendations.
3. A 25-year-old patient with a history of tobacco use receives a 45-minute counseling session on smoking cessation strategies, including nicotine replacement therapy and support resources.
4. A 40-year-old patient with a family history of breast cancer receives a 45-minute counseling session on breast cancer risk reduction strategies, including regular screenings and lifestyle modifications.
5. A 50-year-old patient with a history of obesity receives a 45-minute counseling session on weight management strategies, including portion control, meal planning, and physical activity recommendations.
6. A 35-year-old patient with a family history of colon cancer receives a 45-minute counseling session on colon cancer risk reduction strategies, including regular screenings and dietary modifications.
7. A 20-year-old patient with a history of substance abuse receives a 45-minute counseling session on relapse prevention strategies, including coping skills, support resources, and treatment options.
8. A 60-year-old patient with a history of hypertension receives a 45-minute counseling session on blood pressure management strategies, including medication adherence, dietary changes, and stress reduction techniques.
9. A 45-year-old patient with a family history of osteoporosis receives a 45-minute counseling session on bone health strategies, including calcium and vitamin D supplementation, weight-bearing exercises, and fall prevention measures.
10. A 55-year-old patient with a history of high cholesterol receives a 45-minute counseling session on cholesterol management strategies, including dietary changes, physical activity recommendations, and medication adherence.