Gastroenterology Coding Alert

Know when to apply the newly introduced transitional care codes.

The most widespread changes throughout CPT^® 2013 — the switch to more inclusive or provider-neutral language — shouldn’t be difficult for gastro practices to put into place. Read on for advice on applying E/M with these clarifications and other tidbits from speakers at the American Medical Association’s (AMA) annual CPT^® and RBRVS Symposium, held Nov. 14-16 in Chicago. "The concepts are pretty straightforward," said Richard Duszak, Jr., M.D., an AMA CPT^® Editorial Panel member and practicing radiologist. "There’s been an evolution in CPT^® for how codes report services by non-physicians."

Result: Hundreds of codes were revised for 2013 to include "provider neutral language." Codes throughout the book have replaced designations of "physician" with "individual" or "qualified health care provider."

Exception: A few codes retained the "physician" language, such as those related to skilled nursing facility admissions, because regulations require that a physician admit the patient.

"CPT^® is not the turf police," Duszak said. "We’re focusing on the services provided and recognize that sometimes professionals other than physicians are qualified to provide some services. As a nationally recognized reporting system, it’s important for CPT^® to maintain provider neutrality."

Apply New Transitional Care Codes

CPT^® 2013 introduces two new codes for transitional care management (TCM) services:

99495 — Transitional care management services with the following required elements: communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge; medical decision making of at least moderate complexity during the service period; face-to-face visit, within 14 calendar days of discharge

99496 — ... medical decision making of high complexity during the service period; face-to-face visit, within 7 calendar days of discharge.

The codes are meant to represent situations when a physician oversees an established patient whose medical/psychosocial issues require moderate to high complexity medical decision making (MDM) during the shift from a healthcare facility setting back to the patient’s community (home) setting. Another key to determining whether to report 99495 or 99496 hinges on timely follow-up — how many days pass between the patient’s discharge and when the physician is able to see the patient.