Modifier Coding Alert

Modifier 25 might be the key to your claims with these new/revised codes.

When CPT^® 2016 takes effect on Jan. 1, coders will have a new arrow in their E/M coding quiver.

The latest iteration of the coding manual will include two new E/M codes that could be beneficial to your practice, especially when nonphysicians provide portions of an E/M service. Read on for the info you’ll need to be on target with these new codes — and which modifier you might need to make the new codes work for you.

Say ‘Hello’ to 99415, 99416

CPT^® 2016 features a pair of add-on codes that will enable you to capture nonphysician work that staffers perform after the physician sees the patient for an E/M service. Starting Jan. 1, 2016, 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]), when appropriate to the encounter.

The addition of these codes is causing cautious optimism among coders. “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. “I am anxious to see how these codes play out in policy and, if reimbursable, what might that reimbursement look like.”

“Often, a physician’s time with the patient only paints a partial picture of what occurred during the visit,” Hauptman says. “For example, staff might give the patient an injection, provide education for a new medication or therapy, or provide guidance or service that goes far past the time associated with the E/M code. Now, CPT^® is giving coders a way to recognize that nonphysician work.”

Keep Modifier 25 Handy For 99415/99416 Claims

Using the new prolonged services codes could mean that you have to employ modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) in certain situations.

Example: The physician performs a level-three E/M service for an established patient and determines that he needs a joint injection. The nurse explains the procedure to the patient and performs a lidocaine injection without guidance. After the injection, the patient experiences slight lightheadedness, sweats, and a bit of nausea. The nurse talks with the patient and determines that he is suffering from minor anxiety. She assures the patient that he will be OK. The physician then goes back in to the room and administers the joint injection.  Notes for the encounter indicate that the physician spent 13 minutes providing E/M service pre-injection, while the nurse spent 17 minutes counseling the patient before and after the injection.

On this claim, you would report 99213 (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 …) for the E/M service with modifier 25 appended. Then, you’d report 99415 for the extra E/M time, along with 20610 (Arthrocentesis, aspiration and/or injection, major joint or bursa [e.g., shoulder, hip, knee, subacromial bursa]; without ultrasound guidance) for the injection.

“The staff [members] in a physician’s office are important to the care of the patient and also are an expense to the physician,” Hauptman says. “These codes make good sense all around.”

Best bet: Keep an eye on these codes in 2016, in the coding news, and in your coding community. Medicare will likely hand down some kind of guidance on 99415/99416, and other payers might follow suit.

Use Updated Prolonged Services E/Ms for Psychotherapy

In 2016, you’ll also have a revised set of E/M codes that should make coding for prolonged services that include psychotherapy a lot easier.

CPT^® 2016 will include updates to the following codes (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).

According to Hauptman, these codes will only help you capture the pay you deserve when you are coding for prolonged services that involve psychotherapy. “This type of care, inherently, requires time — and often more time than was reportable prior to this [code] change,” she says.

“Also further clarifying when to use the code — ‘beyond the typical service time of the primary procedure’ — illustrates that it could be added on to any service level; not just the highest,” Hauptman says.

Modifiers: No one knows exactly which modifiers you might need in which situations for 99354/99355, Hauptman says. As providers start using the codes, however, the payers will start giving feedback.

Best bet: As with any revised or new codes, keep your ear to the ground about 99354/99355, and how you might use modifiers with the codes. Visit coding chat rooms, and talk to your local coding community experts, to see who’s using the code, which modifiers you might need, and how payers are receiving the codes.

Also, check Medicare transmittals regularly. As 2016 progresses, “we’ll have to see how CMS develops policy around these clarifications,” Hauptman says.

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