Pediatric Coding Alert

Significant deletions, revisions are coming to virtual E/M.

The digital world is constantly changing, and nowhere is that more evident than in the revisions to the CPT^® online evaluation and management (E/M) service codes that are poised to take place on January 1, 2020.

If your practice uses these codes, or is considering adopting them in the near future, this guide will get you up to speed quickly and painlessly. And we’ve included some expert opinion to help you make sense of it all.

No more 99444

The latest round of CPT^® revisions has kept many of the restrictions to virtual E/M services despite deleting the existing code and replacing it with a new code and two time-based add-ons.

The deleted code is 99444 (Online evaluation and management service provided by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient or guardian, not originating from a related E/M service provided within the previous 7 days, using the Internet or similar electronic communications network). In its place, CPT^® will introduce 99421 (Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes) on January 1.

Like its predecessor, 99421 has some significant restrictions, which stipulate that the service has to be:

• Provided to an established patient (or guardian),
• Provided by a physician or other qualified health care professional (QHP), and
• Unrelated to an E/M service provided within the previous seven days.

This means that any online digital E/M service that results from a previous, or that results in a subsequent, E/M visit is not separately reported, and the online E/M service is incorporated into the related E/M visit.

In addition, CPT^® has placed a seven-day cumulative time limitation on 99421 and made the code time-dependent. You will be able to use 99421 if your provider spends between five and 10 minutes on any asynchronous communications with the patient in that time; you will also be able to report longer time increments with 99422 (… 11-20 minutes) or 99423 (… 21 or more minutes).

Virtual QNHP E/Ms Get Time Changes

Code 98969 (Online assessment and management service provided by a qualified nonphysician health care professional to an established patient or guardian, not originating from a related assessment and management service provided within the previous 7 days, using the Internet or similar electronic communications network) will also become history come January 1.

In its place, you’ll be able to use three new time-based codes to report the same, asynchronous online services to your patients:

• 98970 (Qualified nonphysician health care professional online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes)
• 98971 (… 11-20 minutes)
• 98972 (… 21 or more minutes).

The changes here have been welcomed by our coding experts, as they bring the codes into line with several similar services. “These new codes mimic the qualified nonphysician health care professional [QNHP] telephone call codes 98966-98968 [Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment …], which have the same stipulated times,” notes Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

“They also mirror what has been done to the corresponding physician code 99444,” adds Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

But both experts add a note of caution about the new codes, especially in terms of the criteria that need to be met in order for them to be used. “As noted in the descriptor, these codes are for QNHPs,” cautions Moore. Additionally, “they can only be used for established patients,” notes Holle.

Lastly, “coders will need to work with their providers to figure out how the provider is going to track the time over the seven days and report the appropriate code when the seven days are up,” Moore advises coders. And even if you follow the guidelines to the letter, “like the telephone call codes, these new digital codes may not be payable,” Holle notes. Consequently, coders should check with the payers to whom they submit claims most often to learn how those payers intend to handle these codes.