Coding for Opioid Use and Counseling

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 and Counseling:

• O99.320 Drug use complicating pregnancy, unspecified trimester
• O99.321 Drug use complicating pregnancy, first trimester
• O99.322 Drug use complicating pregnancy, second trimester
• O99.323 Drug use complicating pregnancy, third trimester
• O99.324 Drug use complicating childbirth
• O99.325 Drug use complicating the puerperium
• F11.10 Opioid abuse, uncomplicated
• F11.11 Opioid abuse, in remission
• F11.12 Opioid abuse with intoxication
• F11.14 Opioid abuse with an opioid-induced mood disorder
• F11.15 Opioid abuse with an opioid-induced psychotic disorder
• F11.18 Opioid abuse with other opioid-induced disorder
• F11.19 Opioid abuse with an unspecified opioid-induced disorder
• F11.2 Opioid dependence
• F11.9 Opioid use, unspecified

Counseling

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. 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.

Possible procedure codes are the following:

99401–99404 Preventive medicine, individual counseling

99411–99412 Preventive medicine, group counseling

Specific CPT codes have been developed for tobacco cessation counseling. These services are reported as follows:

  • 99406 Preventive medicine, Smoking/tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes
  • 99407 Preventive medicine, Smoking/tobacco use cessation counseling visit; intensive, greater than 10 minutes

For counseling groups of patients with symptoms or established illnesses, use CPT code 99078.

If the encounter was for other treatment for a patient with a diagnosis of tobacco use or nicotine dependence, report an office or other outpatient E/M code. These codes list a “typical time” 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 medical decision-making.

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. 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.

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