Pediatric Coding Alert

Take note of these changes to prolonged services, care management codes.

While CPT^® 2021 introduces many services that could be used in a pediatric setting, including several new therapeutic drug assays and a number of new codes for documenting reports, scanning analyses, reviews, and interpretations of external electrocardiographic recordings, the revisions to the evaluation and management (E/M) codes will probably have the greatest impact in the peds coding world.

So, here is a brief overview of the CPT^® E/M code changes that will affect you when they take effect on Jan. 1, 2021.

Office and Outpatient E/M Revisions Confirmed …

Many of the changes are simply solidifying the Centers for Medicare & Medicaid Services’ (CMS’) overhaul of the office or other outpatient E/M service codes that we have reported on before. So, the revisions confirm:

• the deletion of 99201 (Office or other outpatient visit for the evaluation and management of a new patient …);
• the deletion of the five-minute typical time for 99211 (Office or other outpatient visit for the evaluation and management of an established patient …), though the descriptor remains otherwise unchanged;
• and a change in the descriptors and time parameters for 99202-99205 and 99212-99215, which now read, in part, “Office or other outpatient visit for the evaluation and management of a new/established patient, which requires a medically appropriate history and/or examination and … medical decision making ….”

… While the Prolonged Services Placeholder Gets a Permanent Code

In addition, CPT^® has given the prolonged office and outpatient services placeholder code 99XXX the official designation of +99417 (Prolonged office or other outpatient evaluation and management service(s) …; each 15 minutes …). So, when the time exceeds 60-74 minutes in the case of 99205, or 40-54 minutes in the case of 99215, you will use one unit of +99417 for every 15-minute increment over the designated times.

Importantly, “you will only be able to use the code with CPT^® codes 99205/99215, which must be selected based on time and not on medical decision making [MDM]. If the code was selected based on medical decision making, +99417 may not be reported,” notes Donna Walaszek, CCS-P, billing manager, credentialing/coding specialist for Northampton Area Pediatrics, LLP, in Northampton, Massachusetts.

How to count time in 2021: In accordance with the revised descriptors for 99202-99205 and 99212-99215, total time should be calculated for “the date of the encounter.” Additionally, the use of the words “with or without direct patient contact” in the descriptor for +99417 reminds you that beginning on Jan. 1, 2021, you will be able to count face-to-face and non-face-to-face time spent on a specific patient’s care.

However, “what can be considered toward total time and how providers should document it within the medical record still remains unclear, and practices should reach out to their payers for guidance,” Walaszek advises.

… While Current Prolonged Services Codes Get Revised …

Meanwhile, the prolonged services codes you’ve been using aren’t going away. CPT^® 2021 has revised them in the following way:

• +99354 (Prolonged service(s) in the outpatient setting requiring direct patient contact beyond the time of the usual service; first hour (List separately in addition to code for outpatient Evaluation and Management or psychotherapy service, except with office or other outpatient services [99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215]))
• +99355 (… each additional 30 minutes (List separately in addition to code for prolonged service))

As the revised descriptor makes clear, “you will no longer be able to use +99354/+99355 with 99202-99215,” notes Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

“However, you will still be able to use the codes with other time-based E/M services,” Falbo adds. These include 99241-99245 (Office consultation for a new or established patient …), 99341-99350 (Home visit for the evaluation and management of a new/established patient …), and 99483 (Assessment of and care planning for a patient with cognitive impairment …).

… Chronic Care Management Gets a New Prolonged Services Add-On …

In a move to bring chronic care management services time reporting in line with complex chronic care management, CPT^® 2021 has changed the time parameters of 99490 (Chronic care management services …). Instead of the code representing “at least 20 minutes of clinical staff time,” next year you will use it to report the “first 20 minutes of clinical staff time.” And you can now use units of new code +99439 (… 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)) to report additional 20-minute time increments per calendar month as outlined in the code’s descriptor.

… and Complex Chronic Care Management Gets 2 Small Tweaks

The last major E/M change that will take effect on January 1 concerns 99487 (Complex chronic care management services …). Like 99490, CPT^® has changed the time parameter language of the code descriptor to make it clearer that the code describes the “first 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.”

Hopefully, this change “will decrease the challenge of reporting complex chronic care management slightly,” says Falbo.

Additionally, CPT^® has deleted the code’s current language calling for the “establishment or substantial revision of a comprehensive care plan.” In the New Year, you’ll have to document that your pediatrician’s comprehensive care plan has been “established, implemented, revised, or monitored,” suggesting that “no longer will you have to document a substantial care plan change in order to bill the code,” Falbo adds.