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2025 CPT code 99403

Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 45 minutes.

Consult the official CPT coding guidelines for accurate coding practices. These guidelines are subject to change and are not included in the provided data.

Modifier 25 may be appended if a significant, separately identifiable E/M service was performed on the same day.

Medical necessity is established when the patient presents without a specific illness, and counseling is required to address preventive measures or modify risk factors.The documentation should clearly demonstrate the need for the extended counseling session.

The provider conducts a face-to-face counseling session with the patient lasting approximately 45 minutes to discuss preventative measures, risk factors, and behavior modification strategies based on the patient's age, history, and any relevant test results.

IMPORTANT:Codes 99401, 99402, and 99404 represent similar services with varying durations (approximately 15, 30, and 60 minutes, respectively).If counseling/anticipatory guidance/risk factor reduction interventions are provided at an encounter separate from a preventive medicine examination, codes 99401-99404 should be used;if provided during a preventive medicine examination, codes 99381-99397 should be used. For behavior change interventions, see codes 99406-99409.For immunization administration and vaccine risk/benefit counseling, see codes 90460, 90461, 90471-90474, 90480. For vaccine/toxoid products, see codes 90476-90759, 91304, 91318-91322.

In simple words: This code covers a meeting with a doctor to talk about ways to stay healthy and avoid getting sick.The meeting lasts about 45 minutes and focuses on things like healthy eating, exercise, avoiding risky behaviors, and managing family issues. It's separate from a regular doctor visit and usually happens after any tests have been done.

This CPT code reports preventive medicine counseling and/or risk factor reduction interventions provided to an individual during a separate encounter from a preventive medicine visit.The session lasts approximately 45 minutes and addresses age-appropriate issues such as family problems, diet and exercise, substance use, sexual practices, injury prevention, dental health, and review of available diagnostic and laboratory test results.This code is used for individuals without a specific illness for which the counseling might otherwise be used as part of treatment.The counseling should focus on preventing problems from developing and reducing risky choices and behaviors.This service is distinct from evaluation and management (E/M) services and should be reported separately. If E/M services are performed on the same day, modifier 25 should be used.

Example 1: A 35-year-old female patient presents for counseling regarding family planning options after reviewing her recent pap smear results., A 16-year-old male patient receives counseling on substance abuse prevention and healthy relationship building., A 60-year-old male patient is counseled on risk factors for cardiovascular disease and provided guidance on diet and exercise modifications.

Detailed documentation should include the date of service, the time spent in counseling, the topics discussed (with specific examples), any patient education materials provided, and a summary of the patient's understanding and plan for implementation of recommendations.Note that the service is separate from a preventive medicine visit. Any related lab results or other findings should be referenced.

** This code should only be used for preventive counseling sessions lasting approximately 45 minutes that are separate from other E/M services.If the session is shorter or longer, a different code may be required (99401, 99402, 99404). The counseling must focus on risk factor reduction and prevention of future illness.

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