Cases , Coding

Mark Gittleman, MD/

Dr. Gittleman's Coding Corner: Coding for Risk Assessment

Question: A member recently asked:

Just curious what codes you guys are using for doing a full risk assessment with multiple models (like the Hughes Risk assessment tool) and for the associated counseling.  I had previously been using the 99420 – risk assessment test – with an attached Z code, but that code was discontinued so we started using 96160 risk assessment.  However, this is apparently the code used for risk assessment associated with social behaviors such as smoking, drinking, texting while driving, etc. and is contractually covered by insurance companies for  our primary care physicians as part of their routine screening during well exams.  Because of this contracting, it can not be used as a separate code for any patient in our system.    Do any of you have advice about how to bill for the data collection, risk assessment and counseling for high risk patients either with family histories or with high risk lesions such as ADH.


In my opinion, rather than using 96160, which may be inappropriate, and has a RVU of 0.13 (!!!), use the appropriate office visit E/M codes and then add on the prolonged service code (99354, 99355) if applicable.

The following lists the new pt, est pt, and consult codes along with their average time spent with pt and their RVUs. I am not listing the level 1-2, but only the 3-5 levels:

Code   avg time     Non-Facility RVU   Facility RVU


99203  30 min             3.05                  2.17

99204  45 min             4.63                  3.67

99205  60 min             5.83                  4.78


99213  15 min             2.06                  1.41

99214  25 min             3.03                  2.72

99215  40 min             4.08                  3.14


99243  40 min             3.45                  2.70

99244  60 min             5.16                  4.34

99245  80 min             6.29                  5.37


Now, determine the appropriate office encounter code, and if the time spent was 30 minutes or greater than the average time for that code, add 99354 X 1 for any time greater than 30-74 minutes. If greater than 75-104 minutes, in addition add 99355 X 1.The 99354 RVU is 3.66 NF ; 3.45 F and the 99355 RVU is 2.76  NF; 2.56 F.

FYI , the 2017 Medicare conversion factor is 35.89.

The ICD-10 codes are either Z12.39 or Z13.79

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