Pediatric Coding Alert

But prolonged clinical staff services coding stays the same.

In the April issue of Pediatric Coding Alert, we took an in-depth look at the way medical decision making (MDM) will function as one of the two ways you will determine office and outpatient evaluation and management (E/M) levels beginning Jan. 1, 2021.

This month, we take a closer look at the second of those ways: time. Here are the four big changes to the way you will use it in your coding in just a few short months, along with one familiar guideline that will remain unchanged next year.

Change 1: Counseling no Longer Has to Factor Into Time Calculations

Up until now, you have been restricted to using time only “when counseling and/ or coordination of care dominates (more than 50 per cent) the encounter” per the current CPT^® guidelines.

However, “starting in 2021, physicians will no longer need to establish how much time was devoted to counseling and coordinating on the day of the encounter,” says Donna Walaszek, CCS-P, billing manager, credentialing/coding specialist for Northampton Area Pediatrics, LLP, in Northampton, Massachusetts. Instead, the time of each service, regardless of its nature, can be used to determine an outpatient E/M level.

Change 2: Time Will Be Total, Not Typical

At the beginning of next year, “the time values associated with each office/ outpatient E/M code will change from being ‘typical face-to-face time’ to ‘total time spent on the day of the encounter,’” Walaszek points out.

This means pediatricians and/or other qualified healthcare professionals (QHPs) can count “face-to-face and non-face-to-face time when determining E/M levels, providing the time is personally spent on a patient’s care and the time only takes into account activities that are performed on the day of the visit,” according to Walaszek.

It also means “you will be able to count numerous activities, including any time the provider spends updating a patient’s clinical information in the record, during the day of the visit,” notes Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

Per the 2021 CPT^® guidelines, the full list of those activities includes:

• “Preparing to see the patient (eg, review of tests).
• Obtaining and/or reviewing separately obtained history.
• Performing a medically appropriate examination and/or evaluation.
• Counseling and educating the patient/family/caregiver.
• Ordering medications, tests, or procedures.
• Referring and communicating with other health care professionals (when not separately reported).
• Documenting clinical information in the electronic or other health record.
• Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver.
• Care coordination (not separately reported).”

Coding caution: “You will not be able to include time clinical staff normally spend doing their activities,” notes Walaszek.

Change 3: Times Will Change and Be a Range

Rather than a single “typical” time, CPT^® has assigned each outpatient E/M level its own time range, as the following table illustrates:

Change 4: Prolonged Services Coding Will Change, Too …

Currently, reporting prolonged services with direct patient contact involves appending add-on codes +99354 (Prolonged evaluation and management … requiring direct patient contact beyond the usual service; first hour …) and +99355 (… each additional 30 minutes …) to any outpatient E/M level. These codes can be added to any E/M service that is based on the elements (history, exam, and/or decision making) once the typical time for that code has been exceeded, or to the highest-level E/Ms when calculated based on time.

Similarly, for outpatient E/M services without direct patient contact, you are currently using a stand-alone code, 99358 (Prolonged evaluation and management service before and/or after direct patient care; first hour), with the add-on +99359 (… each additional 30 minutes …).

After Jan. 1, 2021, however, you will no longer use these codes for outpatient E/Ms 99202-99215. Instead, you will use just one new code: 99XXX. Per its descriptor, you will use this code:

• For prolonged services with or without direct patient contact;
• Only in addition to codes 99205, 99215 when they have been selected using total time;
• On the date of primary service; and
• For each additional 15 minutes of service.

So, a new patient outpatient E/M lasting between 90-104 minutes would be billed by time using 99205x1 and 99XXXx2, while an established patient outpatient E/M lasting 55-69 minutes would be billed by time using 99215x1 and 99XXXx1.

… but Prolonged Clinical Staff Services Coding Will Stay the Same

Fortunately, under CPT^® 2021 this will not change. You will continue to report +99415 (Prolonged clinical staff service … direct patient contact with physician supervision; first hour) and +99416 (… each additional 30 minutes …) in the same way as you have been since the codes were introduced in 2016 for any prolonged E/M service, including 99202-99215, “that involves prolonged clinical staff face-to-face time beyond the typical face-to-face time of the E/M service,” and when a “physician or qualified health care professional is present to provide direct supervision of the clinical staff.”

The bottom line? “Beginning next year, to avoid under-or overcoding outpatient E/Ms, you and your provider will have to be meticulous about keeping track of everything,” cautions Falbo.

(For the full list of CPT^® outpatient E/M and prolonged services guideline changes, go to www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf).