EM Coding Alert

CCI edits, payer problems, create coding uncertainty.

If you’ve hesitated to use the new interprofessional telephone codes since came into existence on January 1, 2019, you’re probably in good company. That’s because they seem to be creating more questions than answers.

One reason the codes are being seen as problematic is probably due to their consultative nature. Simply put, payers who have traditionally baulked at paying for consults will probably view these new codes in the same light.

Additionally, the codes were immediately bundled as Correct Coding Initiative (CCI) procedure-to-procedure (PTP) edit pairs for many other services in the first round of CCI edits published at the beginning of the year, leaving them ineligible for payment anyway.

So, we reached out to some experts to explain this latest development in the world of telemedicine.

What Do the Codes Describe?

The two new codes in question are:

• 99451 — Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a written report to the patient’s treating/requesting physician or other qualified health care professional, 5 minutes or more of medical consultative time
• 99452 — Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting physician or other qualified health care professional, 30 minutes.

According to CPT^® coding guidelines, you can use 99451 when the provider you’re coding for is acting as a consultant. In this situation, the provider accesses the patient’s medical record via telephone, internet, or electronic health record (EHR). The provider then evaluates whatever records are available – history and physical, lab results, imaging reports, surgical reports, etc. – and provides an opinion on the case by sending the referring provider (the treating or requesting physician or other qualified healthcare professional) a written report of treatment/management recommendations.

The difference between this service and the service described by 99452 is that, with 99452, you’re reporting for the other side of the equation as the patient’s primary provider rather than the consulting provider. Guidelines state that 99452 represents when a provider (such as the patient’s primary care physician or other qualified health care professional) interacts with a consulting provider via telephone, the internet, or an EHR. The communication is initiated so the primary provider can share information with the consultant to help him or her form an opinion about the patient’s future treatment or care management.

Coding note: “Referrals of the kind described by 99452 are usually performed by clinical staff in an office, not the provider,” says Donelle Holle, RN,  a healthcare, coding, and reimbursement consultant in Fort Wayne, Ind.

What do the CCI Edits Mean for 99451 and 99452?

Given the newness of the codes, it’s not surprising that they featured heavily in the CCI edits for the first quarter of 2019. In those edits, 99451 and 99452 were listed as Column 2 codes in numerous edit pairs. This signifies that the services associated with 99451 or 99452 are considered as secondary. Or, to put it another way, as column two codes, CMS considers 99451 and 99452 as, in part or completely, included in other procedures (the column one codes).

Additionally, every edit pair that included 99451 or 99452 was assigned a modifier indicator of “0,” meaning that “If a provider reports the two codes of an edit pair for the same beneficiary on the same date of service and the CCMI is 0, the column two code is denied, and the column one code is eligible for payment” per CMS guidelines (Source: www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Downloads/ncci_correspondence_language_manual.pdf).

So, to put it simply, if you do bill for 99451 or 99452 in conjunction with other, primary codes, they will go unpaid even when appended with a modifier.

Payers Still Reluctant to Reimburse for Consultation Services

Other problems with 99451 or 99452 seem to be linked to the bigger picture regarding payers’ reluctance to pay for consultations and other similar non-face-to-face services.

So, if you do report 99451 or 99452 as a stand-alone service, be cautious with your reimbursement expectations. Experts such as Melanie Witt, RN, MA, an independent coding consultant in Guadalupita, NM, stress that “It remains to be seen if payers will reimburse for these services, as generally a face-to-face encounter is usually required. If the payer currently does not reimburse for interprofessional services, it is probably an indication that they will also not pay for these two new services,” Witt points out.

Still, there may yet be some hope for the codes. “As technology communication between physicians and patients becomes more common, these two codes may be used more often by providers as a means of giving or asking for consultative services more frequently and without a face-to-face encounter,” says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook.

“Only time will tell us how often providers will utilize these technology codes in their everyday practice,” Ferragamo concludes. If that is so, then it is possible that payers may be more willing to reimburse for them in the future.

But for now, expect 99451 or 99452 to continue creating their own unique set of coding problems.

(To find all the PTP edits for 2019, go to www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Version_Update_Changes.html and download the zip file “Quarterly Additions, Deletions, and Modifier Indicator Changes to NCCI edits for Physicians/Practitioners” for each quarter.)