Oncology & Hematology Coding Alert

Watch for two new “add-on” E/M codes to capture prolonged clinical staff service. 

As practices adopt ICD-10 now and going forward, they will recognize the significant number of diagnosis assignment and practice changes. Practices will also need to make sure they are prepared to adopt and appropriately utilize the 2016 CPT^® changes.

The coming New Year will provide an opportunity to report additional time providers and staff spend with patients. Flag these changes for E/M codes available in 2016.

Get to Know 99415 and 99416

CPT^® 2016 has two new “add-on” E/M codes to help capture work clinical staff performs after the physician sees the patient for an E/M service.

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 reimbursement as appropriate.

“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 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, education doesn’t have to be provided by 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.”

“CPT^® also indicates these codes [99415, 99416] may not be reported by facilities,” says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, Director of Reimbursement and Advisory Services, Altegra Health, Inc. “So, it is important to remember the clinical staff time spent in an outpatient hospital (example, place of service 22) represents an expense to the hospital, not the physician as the staff are paid by the hospital and reported on the technical (facility) claim.  As little guidance has been published, it is unclear whether Medicare will include these new codes in reporting services and what limitations will be imposed beyond what CPT^® instruction has stated.  Stay tuned for more to come...”

Add Psychotherapy to 99354 and 99355

New codes are not the only change you will need to watch out for in 2016. The CPT^® 2016 code set will update two existing prolonged services codes as follows (emphasis is 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. The psychotherapy codes also require a face-to-face encounter, so it is only logical that it now be included,” Hauptman says. “Additionally, this type of care, inherently, requires time and often more time than was reportable prior to this change. Also further clarifying when to use the code — ‘beyond the typical service time of the primary procedure’ — again illustrates it could be added on to any service level; not just the highest. We’ll have to see how CMS develops policy around these clarifications.”

Check on Descriptor Changes to Prolonged Care and CCM Codes

When CPT^® 2016 goes into effect, you will not only want to be aware of some of the new codes that have been added, understand which codes have been deleted, and be aware of descriptor changes to some of the codes. One such set of codes to pay attention to are the prolonged care codes.

The descriptor changes to these codes in CPT^® 2016 are:

• 99354 (Prolonged service 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]).

“Parenthetical in CPT^® following the prolonged services codes and code 90837 (Psychotherapy, 60 minutes with patient and/or family member) already specify prolonged service codes can be used in addition to 90837 for psychotherapy services not performed with an E/M service of 90 minutes or longer face-to-face with the patient,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. As prolonged care codes are used with E/M and with psychotherapy services when the service extends beyond typical time, the new descriptors have added language consistent with these parenthetical instructions.

Halfway rule: Do not report +99354 “for anything under 30 minutes (above the average time of the normal service),” says Jacqueline Mehalich, RN, CPC, CPC-H, manager of physician education at Allegheny Health Network in Pittsburgh, Pa.

In addition, you would not report the add-on code for an additional 30 minutes (+99355) “for anything that does not extend past the next 15 minutes,” Mehalich says.

Use the following table to get a snapshot of how you should use these codes to capture additional face-to-face time with the patient.

Takeaway pointers:

• The time involved with either code does not have to be consecutive, but it does have to be on the same day.
• You should use +99354 only once per date, even if the time the physician or other qualified health care professional spends is not continuous on that date.
• Use +99355 to report each additional 30 minutes beyond the first hour.
• Do not report when the staff spending time do not represent a cost to the physician (or qualified healthcare practitioner) billing the service.
• Do not report without the appropriate supervision of the staff providing the service.
• Time reported beyond the typical time of the primary service must be past the halfway point of the stated time of the code description to qualify for reporting;

Count Biopsies for Mediastinoscopy

Keep an eye on new coding changes for mediastinoscopy and mediastinal biopsies when treating a patient with lymphoma. Beginning January 1, 2016 no longer report mediastinoscopy with biopsy using 39400 (Mediastinoscopy, includes biopsy (ies), when performed), because CPT^® deletes 39400 code for 2016.

Instead, there are two more specific codes to choose from:

• 39401 — Mediastinoscopy; includes biopsy(ies) of mediastinal mass (e.g., lymphoma), when performed
• 39402 — Mediastinoscopy; with lymph node biopsy(ies) (e.g., lung cancer staging)

“Choose the most specific mediastinoscopy code for your physician’s work based on whether the biopsy involves a mediastinal mass or a lymph node,” says Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, internal audit manager with PeaceHealth in Vancouver, Wash.

2016 Place of Service (“POS”) Code Changes

2016 will bring revisions for POS codes. Currently, we report POS 22 for outpatient hospital services. However, effective Jan. 1, 2016 and implemented January 4, 2016, there are more specific choices to consider for outpatient services. The changes require identifying if the service took place at an “off campus” or “on campus” outpatient hospital location:

POS 19 (Off Campus - Outpatient Hospital) — Descriptor: A portion of an off-campus hospital provider based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

POS 22 (On Campus - Outpatient Hospital) — Descriptor: A portion of a hospital’s main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

Resource: Check out the MLN Matters article from CMS about these and other  new POS codes: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9231.pdf.

Observe Changes to Vaccine Codes

As seen most years, changes to vaccine codes in CPT^® 2016 are included. There are four (4) new vaccine codes to add while making note of many changes to the descriptors of older vaccine codes.

The four new codes for 2016 are:

• 90620 (Meningococcal recombinant protein and outer membrane vesicle vaccine, serogroup B [MenB], 2 dose schedule, for intramuscular use)
• 90621 (Meningococcal recombinant lipoprotein vaccine, serogroup B [MenB], 3 dose schedule, for intramuscular use)
• 90625 (Cholera vaccine, live, adult dosage, 1 dose schedule, for oral use)
• 90697 (Diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, Haemophilus influenzae type b PRP-OMP conjugate vaccine, and hepatitis B vaccine [DTaP-IPV-Hib¬-HepB], for intramuscular use).

In addition, be sure to review new descriptor changes to many of the vaccine codes that may be used in your practice. Also, be sure not to utilize the vaccine codes deleted for 2016.