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.
FAQs:
1. What codes should be assigned for opioid use during pregnancy?
For opioid use during pregnancy, assign codes from subcategory O99.32 and a secondary code from category F11 for opioid-related disorders.
2. What are the specific O99.32 codes?
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.
3. How are counseling services documented?
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.
4. What CPT codes are available for tobacco cessation counseling?
CPT codes 99406 and 99407 are used for intermediate and intensive tobacco cessation counseling, respectively, based on the duration of the visit.
5. How is time spent on counseling recorded for E/M codes?
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.
