Oncology & Hematology Coding Alert

Medicare released its own high-level prolonged services code.

It’s 2021 and you’ve got all your bases covered for the new year — right?

Everyone is probably up to speed on the changes to CPT^®, ICD-10, the Medicare Physician Fee Schedule (MPFS), and the National Correct Coding Initiative (NCCI). But don’t forget about updates to the Healthcare Common Procedure Coding System (HCPCS).

In a nutshell: HCPCS Level II codes “help providers of Medicare, Medicaid, and various third-party insurances get paid for services that are not covered by CPT^® codes,” explains Catherine Brink, BS, CPC, CMM, president of Healthcare Resource Management in Spring Lake, N.J.

Therefore, Brink advises, it is very important to stay current with HCPCS updates. Here’s a look at the HCPCS changes you can expect for 2021.

Check Out 2021 HCPCS Numbers

There are more than 15 different types of HCPCS codes, ranging from A codes for “Transportation, Medical & Surgical Supplies, Diagnostic and Therapeutic Radiopharmaceuticals” to V codes for “Vision/Hearing Services.” The majority of the movement in the HCPCS list involves G codes, “Temporary Procedures & Professional Services.” You will find over 250 changes, additions and revisions in this category. Remember, G Codes are for quality reporting and new services or billing concepts by CMS. In other words, you’ll use G codes when the CPT^® code has yet been identified and requires a slightly longer timeline than getting a code assigned within HCPCS Level II.

“As of January 1, Medicare recognizes 1,278 G HCPCS codes,” explains Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, New Mexico. HCPCS added 50 G codes January 1; seven were for physician services and were assigned relative value units (RVUs), meaning providers can bill and get paid for them.

Watch Out for Changes to Office E/M Coding

Here’s a sampling of the new G codes that represent physician services, along with some expert analysis:

• G2211 (Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition. (add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established))

Analysis: The Centers for Medicare & Medicaid Services (CMS) estimates that specialties who rely on evaluation and management (E/M) services “will use this code 90 percent of the time in conjunction with an office/outpatient visit E/M code,” explains Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians: https://www.cms.gov/files/document/mln-understanding-4-key-topics-call.pdf. However, while the code is active, it does not carry a value for payment and the rules for its use are still unclear.  (For more information, see the article entitled “Track Changes to Bottom Line and More From COVID-19 Relief Bill” in this issue.)

Moore says coders will need to be prepared to add this code to almost every Medicare claim for an office/outpatient E/M: 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter) .

• G2212 (Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services) (do not report g2212 on the same date of service as 99354, 99355, 99358, 99359, 99415, 99416). (do not report g2212 for any time unit less than 15 minutes))

Analysis: Medicare wants coders to use G2212 to represent prolonged services instead of new CPT^® code +99417 (Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required time of the primary procedure which has been selected using total time, requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service, each 15 minutes of total time (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services) — but only in certain situations.

You should only use G2212 on level-five office/outpatient evaluation and management (E/M) services — 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on the date of the encounter) and 99215.

“Private payers’ policies on this service may differ, so it will be important to check whether +99417 or G2212 should be reported,” Witt says. The guidelines for G2212 are similar to CPT^® code +99417, “except CMS made clarifications to the language in the code description that it found unclear, such as the terms ‘total time’ and ‘usual service,’” Witt says.

• G2213 (Initiation of medication for the treatment of opioid use disorder in the emergency department setting, including assessment, referral to ongoing care, and arranging access to supportive services (list separately in addition to code for primary procedure))

Analysis: Witt reports that this is a code that you can report with other emergency department (ED) codes representing initial care: 99281 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making) through 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity).

• G2250 (Remote assessment of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment)
• G2251 (Brief communication technology-based service, e.g. virtual check-in, by a qualified health care professional who cannot report evaluation and management services, provided to an established patient, not originating from a related service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of clinical discussion))

Analysis: These are temporary telehealth codes for providers who cannot bill independently for E/M services. After the COVID-19 public health emergency (PHE) is over, Medicare had intended on deleting these codes. However, as of MLN (MM12126) release implemented on Jan 4, 2021, “CY 2021 rulemaking made these codes permanent, meaning they are no longer restricted by the effectiveness timeline of the Public Health Emergency (PHE) for COVID-19.”

• G2252 (Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion)

Analysis: “The code is intended for situations when the acuity of a patient’s problem is not necessarily likely to warrant an in-person visit, but when additional time is needed to make this assessment,” says Witt. There is no PHE end date for this code yet, explains Witt, as “Medicare will decide later whether to make this code a permanent telehealth service.”

Chronic Care Management Coding Changing

Deletions of G codes that were paid by Medicare include:

• G0297 (Low dose ct scan (ldct) for lung cancer screening)
• G2058 (Chronic care management services, each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (list separately in addition to code for primary procedure). (do not report g2058 for care management services of less than 20 minutes additional to the first 20 minutes of chronic care management services during a calendar month). (use g2058 in conjunction with 99490). (do not report 99490, g2058 in the same calendar month as 99487, 99489, 99491))

Analysis: According to Moore, G2058 was cut because CPT^® 2021 added +99439 (Chronic care management services with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, revised, or monitored; each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure)) is available. “Coders who used G2058 in 2020 will use +99439 in 2021,” explains Moore.

Use +99439 as an add-on code with 99490 (Chronic care management services with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, revised, or monitored; first 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month) representing the primary service.

Editor’s Note: Check out next month’s HCPCS Level II Part 2 Update article to check out the new oncology-related codes.