Oncology & Hematology Coding Alert

And get ready for a possible split/shared shake-up

Oncology coders will find a lot of interesting proposals in Medicare’s Physician Fee Schedule proposed rule for CY 2022. Here are some of the highlights.

Connect Your CPT^® Understanding to CMS’ Critical Care Proposals

One set of proposals that could potentially make your life easier next year involve Medicare realigning their guidelines for 99291/+99292 (Critical care, evaluation and management of the critically ill or critically injured patient …) with CPT^®, including:

• adopting CPT^®’s definition of critical care services as “medical care for a critically ill/ injured patient in which there is acute impairment of one or more vital organ systems, such that there is a probability of imminent or life-threatening deterioration of the patient’s condition …. [and which] involves high complexity decision-making”;
• adopting CPT^®’s bundling of “interpretation of cardiac output measurements (93561, 93562), chest X rays (71045, 71046), pulse oximetry (94760, 94761, 94762), blood gases, and collection and interpretation of physiologic data (for example, ECGs, blood pressures, hematologic data); gastric intubation (43752, 43753); temporary transcutaneous pacing (92953); ventilator management (94002-94004, 94660, 94662); and vascular access procedures” into critical care visits;
• adopting CPT^®’s time-counting guidelines and time parameters for 99291/+99292 for a single physician and requiring practitioners to document total time furnishing critical care service in the medical record;
• allowing for “more than one physician or NPP of the same or different specialties, and within the same or a different group” to furnish critical care services concurrently.
• allowing for critical care to be furnished as split/shared services; and
• not allowing you to bill other evaluation and management (E/M) visits “for the same patient on the same date as a critical care service when the services are furnished by the same practitioner, or by practitioners in the same specialty in the same group.”

Peruse This Proposal for PCM and Additional CCM

“Next year, Medicare is proposing to accept and pay for new CPT^® codes for Principal Care Management (PCM),” says Lori Carlin, CPC, COC, CPCO, CCS, Director, Professional Coding Services, Pinnacle Enterprise Risk Consulting Services LLC, Centennial, Colorado.

The codes in question are:

• 99X22 (Principal care management services, for a single high-risk disease: with the following required elements: one complex chronic condition expected to last at least 3 months, and which places the patient at significant risk of hospitalization, acute exacerbation /decompensation, functional decline, or death, the condition requires development, monitoring, or revision of disease-specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities; ongoing communication and care coordination between relevant practitioners furnishing care; first 30 minutes provided personally by a physician or other qualified health care professional, per calendar month)
• 99X23 (Principal care management services … additional 30 minutes provided personally by a physician or other qualified health care professional …)
• 99X24 (Principal care management services … first 30 minutes of clinical staff time directed by physician or other qualified health care professional, per calendar month)
• 99X25 (Principal care management services each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional …).

“A patient would be eligible for PCM if they have a chronic condition that is expected to last at least three months. It would be a condition which places the patient at significant risk of hospitalization, acute exacerbation/decompensation, functional decline, or death,” Carlin clarifies.

In addition, CMS is also proposing a new code — 99X21 (Chronic care management services each additional 30 minutes by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure) — which you will use as an add-on code for 99491.

Get Ready for a Possible Split/Shared Shake-Up

For 2022, Medicare is proposing to simplify its split/shared policy. If finalized, “the rule will define split/shared services as E/M visits provided in the facility setting by a physician and non-physician practitioner in the same group,” says Jodi Nayoski, CPC, CPC-I, CCS-P, CHC, CDIP, CHIAP, Director, Professional Coding Services, Pinnacle Enterprise Risk Consulting Services LLC.

In the facility setting, the proposal calls for billing the visit under the physician or [non-physician practitioner] NPP who performs the substantive portion of the visit. More, split or shared visits could be reported for new as well as established patients, and initial and subsequent visits, as well as prolonged services,” Nayoski adds. You will also be able to count prolonged service time in split/shared encounters if CMS finalizes the proposal.

Medicare is also considering further tweaks to this policy:

• by further defining the term “group” to align with the definition of “physician organization,” used elsewhere in regulations, or to require that the physician and NPP must be in the same clinical specialty, such that the “NPP is considered to be in the same specialty and subspecialty as the physician with whom they are working” in split/shared encounters;
• by requiring both physician and NPP to be identified in the medical record for split/shared encounters; and
• by proposing an informational modifier be appended to split/shared claims for data-gathering purposes.

(To view the full proposed rule, go to public-inspection.federalregister.gov/2021-14973.pdf?utm_medium=email&utm_campaign=pi+subscription+mailing+list&utm_source=federalregister.gov. CMS will accept comments on the proposed rule electronically, via regular mail, and by express or overnight mail, until 5 p.m. on September 13, 2021. See page 2 of the proposed rule for further information.)