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DOT/SAE Approved

Qanash S, Alemam S, Mahdi E, Softah J, Touman AA, Alsulami A

CPT code 99411 documentation requirements To ensure accurate documentation and payer compliance, the medical record must reflect: Group composition: Minimum of 2 unrelated individuals (not family members) Topics discussed and objectives of the session (e.g., hypertension or obesity prevention) Duration: ~30 minutes per session Description of the counseling and/or risk factor reduction strategies employed Qualifications of the provider or facilitator Outline of services rendered and patient engagement or follow-up This code is not tied to a diagnosis code for a specific illness but may be linked to general risk categories

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