EM Coding Alert

Revised descriptors clarified who can report several codes.

By now, you should be well-versed in using any new codes that CPT^® added for 2013, but you may have missed some code descriptor revisions and other E/M code changes that can benefit your practice.

Nearly every code descriptor in the E/M code section has some change on Jan. 1, 2013. Take a look at this roundup to be sure you haven’t missed any vital details.

Eliminate ‘Physician’ Limitations From Your E/M Code Thinking

Nearly every E/M code has some revision, although the vast majority are for internal consistency with CPT^®’s introductory language acknowledging that not every provider is a physician, says Michael A. Granovsky, MD, FACEP, CPC, President of LogixHealth, a medical coding and billing company in Bedford, MA. There is new language for 2013 in each of the E/M codes, which eliminates the word “provider” and replaces it with “qualified healthcare providers.”

Whereas most E/M codes previously referred to “physicians” and “providers” in their descriptors, on Jan.1 when CPT^® 2013 took effect, the descriptors changed to “qualified health care professionals.”

Using 99213 as an example, the code changes are indicated with the strikethroughs (indicating deleted text) and underlining (indicating new text) as follows: Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other physicians, other providers qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend Typically, 15 minutes are spent face-to-face with the patient and/or family

This really isn’t a change per se, as much as it is a clarification, says Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla.

What this means: “They are clarifying that all E/M codes can be reported by physicians or other qualified health care providers and changed the wording with regard to time in each of the codes — which really has no bearing on how the codes are used, just that the typical time is spent by all qualified providers who bill these codes,” says Melanie Witt, RN, COBGC, MA, an independent coding consultant in Guadalupita, N.M. “In other words, if a payer allows someone other than a physician to provide and bill for a service, the CPT^® E/M codes are used by all providers who qualify.”

“I believe that there are a lot of physician extenders out there,” says Christy Shanley, CPC, department administrator for the University of California, Irvine. “This further clarifies what they can and or cannot perform on their own.”

This change clarifies things in two ways, Mac says: First, the change makes it clear that you can use E/M codes for NPPs. Second, it clarifies that “you have to have that counseling with someone who is certified or technically licensed to provide that type of service; it can’t be your office administrator, so to speak,” she explains. “It is just a clarification, and I think it was understood before but it could have been abused in some way.”

Apply the Change to Your PA/NP Billing

You should have applied these changes for services provided by your physician assistants (PAs) and nurse practitioners (NPs), for example. The E/M service changes indicate nonphysician providers (NPPs), especially PAs and NPs, can provide E/M services on their own, can bill on time alone, and can do counseling and coordination of care on their own.

Time assignment: In addition, CPT^® added typical times to the same-day observation or inpatient admission and discharge codes 99234-99236 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date ...), assigning 40 minutes to 99234, 50 minutes to 99235, and 55 minutes to 99236. Previously, these codes did not have typical times associated with them, so this change could be helpful to physicians who are at the patient’s bedside or on the unit counseling or coordinating care for more than half of the visit, which would allow them to select a code based on time.

Use 99234-99236 With Prolonged Services Codes

The parenthetical note following the prolonged services code descriptor now includes 99234-99236 because with the addition of typical times to the code descriptor, it is possible to quantify when the typical time has been exceed justifying prolonged care, says Granovsky.

·         99356 Prolonged services in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient Evaluation and Management service)

·         (Use 99356 in conjunction with 99218-99220, 99221-99223, 99224-99226, 99231-99233, 99234-99236, 99251-99255, 99304-99310)

Don’t Count Two Way Radio Communications as Pediatric Critical Care

If you work in a pediatric office, you might want to make note of this language change as well for pediatric critical care transport.

The non-face-to-face direction of emergency care to a patient’s transporting staff by a physician located in a hospital or other facility by two-way communication is not considered direct face-to-face care and should not be reported with 99466 and 99467.

·         99466 — Critical care face-to-face services delivered by a physician, face-to-face, during an Interfacility transport of critically ill or critically injured pediatric patient, 24 months of age or younger; first 30-74 minutes of hands-on care during transport

·         99467 — ... each additional 30 minutes (List separately in addition to primary service)

Physician directed non face-to-face emergency care through outside voice communication to transporting staff should be reported using 99288 (Physician or other qualified health care professional direction of emergency medical systems [EMS] emergency care, advanced life support) or 99485 and 99486 based upon age and clinical condition of the patient.

Map in New Codes for Coordination, Transfer of Care

The E/M section contains new E/M codes for coordination of complex care (99487 – 99489) and transitional care management services (99495 – 99496). These codes are the result of a special CPT^® Workgroup tasked with finding a way to capture the additional work associated with these tasks above and beyond what would typically be covered in the post service work of another E/M code such as an inpatient hospital visit. These codes were expedited through the CPT^® process to be ready for 2013 usage, says Granovsky.

The new complex coordination of care codes describe patient management and support services to an individual that require clinical staff to implement a care plan involving multiple disciplines, which are directed by the physician or other qualified healthcare professional. The reporting provider oversees the management and or coordination of needed services for all medical conditions, psychosocial needs and activities of daily living. The typical patient for these coordination codes would have multiple chronic conditions expected to last for the foreseeable future and that place the patient at significant risk of death or decline. Examples would be patients suffering from multiple co-morbidities such as dementia, chronic obstructive pulmonary disease or diabetes that complicate their care, says Granovsky.

Codes 99487-99489 are reported only once per calendar month and include all non-face-to-face complex chronic are coordination services and none or one face-to-face office or other outpatient visit. Only one physician or other qualified health care professional a can report the code for a particular patient during the calendar month, he adds.

Code 99487 is reported when there is no face-to-face visit with the physician during the month and at least 31 minutes of clinical staff time in coordination of care activities. The clinical staff time clock can not include any time spent on the date the physician is reporting another E/M service.

Code 99488 is reported when there is a face-to-face visit with the physician or other qualified health care professional during the month and there is at least 31 minutes of clinical staff time in coordination of care services.

The new codes for transitional care management services (TCM), 99495 and 99496, are for established patients whose medical and/or psychosocial problems require moderate or high complexity medical decision making during transitions in care from an inpatient hospital setting or observation status to the patient’s community setting, be that home, nursing home or assisted living.

TCM starts on the date of discharge and continues for the next 29 days. It includes one face-to-face visit within the specified time frames, in combination with non-face-to-face services that may be performed by the physician or licensed health care profession or clinical staff under their direction. Additional E/M services after the first face-to face may be reported separately, but the first one is included in TMC code, says Granovsky.

The factors that determine which TMC code to report are medical decision making and the date of the first face-to-face visit. For the moderate complexity MDM code 99495, the face to face visit must occur within fourteen days and the higher complexity code 99496 requires the face-to-face visit within seven calendar days. It is the medical decision making over the service period reported that determines which level you should choose. Only one individual can report TMC and only once per patient within 30 days of discharge, Granovsky warns.