Pediatric Coding Alert

Coding Quiz Answers:

Check Your Answers to Our End-of-Year Coding Quiz

Published on Wed Nov 10, 2021

How well do you know these major coding changes from 2021?

Once you’ve answered the quiz questions on page 3, compare your answers with the ones provided below:

Answer 1: When CPT^®introduced the prolonged service 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 …), it instructed you to add one unit of the code when time documented hits 15 minutes beyond the minimum for the 99205 (Office or other outpatient visit for the evaluation and management of a new patient … 60-74 minutes of total time is spent on the date of the encounter) or 99215 (Office or other outpatient visit for the evaluation and management of an established patient … 40-54 minutes of total time is spent on the date of the encounter) time ranges — 75 minutes for a new patient visit and 55 for an established patient — and additional units for every 15 minutes beyond those times.

In the 2021 final rule, the Centers for Medicare & Medicaid Services (CMS) argued that +99417 should be used when the total time for visits hits 15 minutes beyond the maximum time range for 99205 (i.e., 89 minutes) and 99215 (i.e., 69 minutes). To avoid potential confusion with CPT^®guidelines,CMS replaced +99417 with a new prolonged service code now recognized by Medicare and payers following Medicare payment rules: 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 …).

So, if your provider saw an established patient for 90 minutes, you would bill 99215 for the first 40 minutes, and +99417 x 3 for the additional 50 minutes to payers following CPT^®guidelines. Under Medicare guidelines, you would bill the same encounter with 99215 for the first 54 minutes and only two units of G2212. That’s because CMS does not allow the G2212 to be used until 69 minutes have passed. Adding another 15 minutes to 69 minutes would bring you to 84 minutes, which means you can report a second unit of G2212 but not a third.

Answer 2: First, “parent code Z59.4 got a name change from ‘Lack of adequate food and safe drinking water’ to ‘Lack of adequate food’ with the synonym ‘Inadequate drinking water supply’ deleted,” according to Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Next, ICD-10 expanded parent code Z59.4 to two fifth-character codes: Z59.41 (Food insecurity) and Z59.48 (Other specified lack of adequate food), which is accompanied by the synonyms “inadequate food” and “lack of food.”

Last, ICD-10 introduced a new code, Z58.6 (Inadequate drinking-water supply), which is accompanied by the synonym “Lack of safe drinking water.”

Answer 3: Principal care management (PCM) is reserved for patients with “one complex chronic condition expected to last at least 3 months, that places the patient at significant risk of hospitalization,” according to Samuel L. “Le” Church, MD, MPH, CPC, CPC-1, CRC, FAAFP. CPT^®defines a chronic condition as a condition where “the risk of morbidity without treatment is significant” and which is “treated as chronic whether or not stage or severity changes.” In other words, a condition is chronic no matter what its severity or whether it is stable, in a state of exacerbation, or in a stage of progression.

Physicians or other qualified health care professionals (QHPs) such as physician assistants (PAs), certified registered nurse practitioners (CRNPs), or clinical nurse specialists (CNSs) can provide the services, which you would document using 99424 and +99425. Clinical staff, such as medical assistants, licensed practical nurses (LPNs), registered nurses (RNs), and others depending on the scope of practice as defined by state law under the direction of a physician or other QHP, may also provide the services, which you would document with 99426 and +99427

Per the CPT^®descriptors, activities that you can count toward these codes include developing, monitoring, or revising a disease-specific care plan; “adjustments in the medication regimen and/or the management of the condition,” and “ongoing communication and care coordination between relevant practitioners furnishing care.”

“All tasks consistent with the care plan can be billed, including charting,” according to Church. However, you cannot double-dip services such as transitional care or home health oversight. And even though office or hospital evaluation and management (E/M) services can be billed, they must be separate and significant to treatment outlined in the care plan.

PCM services must also follow the office requirements as currently identified in CPT^®. This includes 24/7 patient access to physicians or other QHPs, use of an electronic medical record (EMR) system with a format standardized throughout the practice, and a dedicated care team member responsible for providing continuity of care.

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