Pediatric Coding Alert

Build your CCM, TCM knowledge and increase your bottom line.

In last month’s Pediatric Coding Alert, we noted that the Centers for Medicare and Medicaid (CMS) has introduced primary care management (PCM) beginning Jan.1, 2020.

But the 2020 Physician Fee Schedule (PFS) final rule contained a number of revisions to chronic care management (CCM) and transitional care management (TCM) as well. Here’s how they might impact your coding in the months and years to come.

Add These Revisions to Your CCM Coding

If you have used 99490 (Chronic care management services, at least 20 minutes of clinical staff time …), you know that there hasn’t been a way to report additional time spent by clinical staff on care management for patients with a chronic condition. CMS addressed the issue in this year’s final rule by creating an add-on HCPCS code, 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) …). You’ll be able to report G2058 “a maximum of two times within a given service period for a given beneficiary.” 

“This add-on code means that 99490 will no longer be open-ended, and beneficiaries requiring more time for CCM will potentially generate more revenue to cover the extra costs,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “It’s also consistent with the direction CPT^® is going to go in 2021,” Moore also notes.

But before you use G2058, make sure you contact your payers. “G codes are typically used by Medicare, so this is an exciting revision as long as all the insurance carriers will accept the code,” notes Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

And note these care plan changes: CMS also announced some changes in the typical CCM care plan. Instead of having to document “how the services of agencies and specialists unconnected to the practice will be directed/coordinated” and the names of “individuals responsible for each intervention,” all you need to do now is document that there has been “interaction and coordination with outside resources and practitioners and providers,” according to CMS.

Also, CMS waived the care plan revision requirements for 99487-+99489 (Complex chronic care management …). “Because CMS believes patients needing complex CCM implicitly need and receive substantial care plan revision, the service component of substantial care plan revision potentially duplicates the medical decision-making service component and is unnecessary as a means of distinguishing eligible patients,” Moore explains.

Add Revenue With TCM

If you bill 99495 (Transitional Care Management services … within 14 calendar days of discharge) or 99496 (Transitional Care Management services … within 7 calendar days of discharge) in 2020, you’ll get a small increase in your revenue stream. CMS has raised the work relative value units (RVUs) for both codes, from 2.11 to 2.36 for 99495 and 3.05 to 3.10 for 99496.

CMS will also no longer bundle TCM with a number of related services, which could also add to your practice’s profit margin. The services include international normalized ratio (INR) monitoring services, reported with 93792 (Patient/caregiver training …) and 93793 (Anticoagulant management …); data analysis, reported with 99091 (Collection and interpretation of physiologic data…); non-face-to-face prolonged services, reported with 99358-+99359 (Prolonged evaluation and management services …); CCM and complex CCM, reported with 99490-99491 (Chronic care management services …) and 99487-+99489.

“The TCM codes are great to use when a practice sees a newborn, for example, that has been in the neonatal intensive care unit [NICU] for a period of time and is still on oxygen, tube feedings, heart monitors, and so on,” Holle suggests. So, naturally, “the increase in value and expansion of the list of services that can be reported concurrently with TCM are both good things for pediatrics,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “Not only will you get paid more for providing TCM services, but you’ll also have the opportunity to separately report, and get paid for, other services previously bundled with TCM. This may make it more attractive and/or feasible for you to provide TCM in 2020 and beyond,” Moore adds.

But remember this: You cannot count time counted toward one service to another on the same date. If your pediatrician provides TCM for a patient on a given date of service, that time cannot be counted toward CCM, for example.

And this: The 99495/6 codes require that you document moderate or high complexity medical decision making when the patient is discharged, Holle notes.

Add RPM to Care Management Services

In addition to CPT^® changing the designated time for 99457 (Remote physiologic monitoring treatment management services; …) from “20 minutes or more of clinical staff/physician/other qualified health care professional time” to “initial 20 minutes” and adding +99458 (… additional 20 minutes…) to allow you to report each additional 20 minutes of the service when appropriate, CMS has also designated the service as a care management service.

This means remote physiological monitoring (RPM) can now be “furnished under general supervision … of the ‘physician or other qualified health care professional …,’” meaning that the services can now be billed “incident to the services of a physician or other qualified healthcare professional” per CMS regulation Section 410.26(b)(5) according to the final rule. In other words, “this is another area that practices can maximize reimbursement performed by clinical staff and not just provider staff,” Holle adds.

To view the full PFS final rule for 2020, go to s3.amazonaws.com/public-inspection.federalregister.gov/2019-24086.pdf.