Gastroenterology Coding Alert

Revised codes can be added on to any service level, not just the highest.

Change has come visiting again. While you are already coping with the ICD-10 implemented recently, you should get ready to grapple with CPT^® updates that come into effect on Jan. 1, 2016.

The good news is there are relatively few E/M code changes, and we’ve got the details you need to know. Read on to learn the options you’ll have in the new year for reporting the above and beyond time your providers and staff spend with patients.

Get to Know 99415 and 99416

CPT^® 2016 will debut two add-on E/M codes to help you capture work your clinical staff performs after your physician sees the patient for an E/M service. You will be able to report 99415 (Prolonged clinical staff service [the service beyond the typical service time] during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour [List separately in addition to code for outpatient Evaluation and Management service]) and 99416 (…each additional 30 minutes [List separately in addition to code for prolonged services]) to seek additional, deserved reimbursement.

“Now here is a set of codes to really sink your teeth into; we hope!” says Suzan (Berman) Hauptman, MPM, CPC, CEMC, CEDC, director of PB Central Coding at Allegheny Health Network in Pittsburgh, Pa. “Often times a physician’s time with the patient only paints a partial picture of what occurred during the visit. It could have been that the staff was asked to give an injection, but the patient was uncooperative. It might include education for a new medication, therapy, or options for care that go far beyond the time illustrated in the E/M code, but, that education doesn’t have to be that of the physician. The staff [members] in a physician’s office are important to the care of the patient and also are an expense to the physician. These codes make good sense all around to be included in the new code sets. This may also come into play with the trend of coverage for more preventive services. I am anxious to see how these codes play out in policy and, if reimbursable, what might that reimbursement look like.”

“Be sure to pay attention to the Medicare Physician Fee Schedule that is typically published in the Federal Register towards the end of November,” cautions Carol Pohlig, BSN, RN, CPC, ACS, Senior Coding & Education Specialist at the Hospital of the University of Pennsylvania. “The code status designation will directly affect reimbursement opportunities. If given a “B” status, as most codes of this same nature, the reimbursement is considered bundled (e.g., into the payment for the physician service), and not separately reported,” she adds.

Add Psychotherapy to 99354/5

New codes aren’t the only thing you’ll need to watch out for in 2016. CPT^® 2016 updates two existing prolonged services codes as follows (emphasis added to show the revisions):

• 99354 — Prolonged evaluation and management or psychotherapy service[s] [beyond the typical service time of the primary procedure] in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour [List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service]
• 99355 — ... each additional 30 minutes [List separately in addition to code for prolonged service].

“Good to see that CPT^® is including psychotherapy in the prolonged services code set. These services require a face-to-face encounter, so it is only logical that it now be included as a primary code to the prolonged care service,” Hauptman says. “Additionally, this type of care, inherently, requires time and often more time than was reportable in the primary code prior to this change. Also further clarifying when to use the code — ‘beyond the typical service time of the primary procedure’ — aligns the language with the correct code use, that it could be added on to any service level; not just the highest. Medicare always allowed this, so it is not new, it’s just a language realignment. We’ll have to see how CMS develops policy around these clarifications.”