The following Current Procedural Terminology (CPT®) codes can be used for driver assessment and counseling, when applicable. These codes were taken from Current Procedural Terminology (CPT®). 4th ed., Professional ed. Chicago, IL: American Medical Association; 2003.
When selecting the appropriate CPT® codes for driver assessment and counseling, first determine the primary reason for your patient’s office visit, as you would normally. The services described in this Guide will most often fall under Evaluation and Management (E/M) services. Next, select the appropriate E/M category/subcategory. If you choose to apply codes from the Preventive Medicine Services category, consult Table 1 for the appropriate codes. If any additional services are provided over and above the E/M services, codes from Table 2 may be additionally reported.
If the primary reason for your patient's visit falls under the E/M category of Preventive Medicine Services, choose one of the following codes:
|99386 40-64 years
99387 65 years and older
|New Patient, Initial Comprehensive Preventive Medicine
Evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunizations(s), laboratory/diagnostic procedures.
These codes can be used for a complete Preventive Medicine history and physical exam for a new patient (or one who has not been seen in three or more years), which may include assessment and counseling on driver safety. If significant driver assessment and counseling take place during the office visit, Modifier-25 may be added to the codes above.
|99396 40-64 years
99397 65 years and older
|Established Patient, Periodic Comprehensive Preventive Medicine
Reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures.
Codes from the Preventative Medicine Services 99386-99387 and 99396-99397 can only be reported once per year. If driver assessment and counseling take place during the office visit, Modifier-25 may be added to the codes above.
|99401 Approximately 15 minutes
99402 Approximately 30 minutes
99403 Approximately 45 minutes
99404 Approximately 60 minutes
|Counseling and/or Risk Factor Reduction Intervention
Preventive medicine counseling and risk factor reduction interventions provided as a separate encounter will vary with age and should address such issues as family problems,diet and exercise, substance abuse, sexual practices, injury prevention, dental health, and diagnostic and laboratory test results available at the time of the encounter. (These codes are not to be used to report counseling and risk factor reduction interventions provided to patients with symptoms or established illness.) These are time-based codes, to be reported based upon the amount of time spent counseling the patient.
Driver safety or driving retirement counseling fall under the category of injury prevention. Please note that for driving retirement counseling, a copy of the follow-up letter to your patient can be included in the patient's chart as additional documentation. A sample letter can be found in Chapter 6.
The codes below can be used for administration of ADReS (see Chapter 3). If you complete the entire assessment, you can include codes 99420, 95831 and either 99172 or 99173. The ADReS Score Sheet can serve as the report
|99420||Administration and Interpretation of Health Risk Assessment Instrument|
|95831||Muscle and Range of Motion Testing
Muscle testing, manual (separate procedure)with report; extremity (excluding hand) or trunk.
|99172||Visual Function Screening
Automated or semi-automated bilateral quantitative determination of visual acuity, ocular alignment, color vision by pseudoisochromatic plates, and field of vision (may include all or some screening of the determination(s) for contrast sensitivity, vision under glare).
|99173||Screening Test of Visual Acuity, quantitative, bilateral
The screening used must employ graduated visual acuity stimuli that allow a quantitative estimate of visual acuity (eg, Snellen chart).