Pediatric Coding Alert

Make sure you bill email communications correctly this year.

Late last year, the Centers for Medicare & Medicaid Services (CMS) released the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edit pair additions, deletions, and modifier indicator changes for the first quarter of 2020.

As usual for the first quarter of a new year, the changes are extensive, and we only have space here for a few brief highlights. So, we’ve focused on the new online evaluation and management (E/M) codes that became effective on January 1, as they feature extensively among the revisions.

Look to Guidelines to Explain Digital E/M Pair Edits …

Codes 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), 99422 (… 11-20 minutes), and 99423 (… 21 or more minutes), which describe patient-initiated communications through “electronic health record [EHR] portals, secure email, or other digital applications,” are already subject to pretty stringent CPT® guidelines.

In part, the guidelines “prohibit separately reporting any online digital E/M service that is the result of an E/M visit that has occurred within the past seven days, or that results in a subsequent E/M visit in the next seven,” according to Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana. “In such cases, the online digital E/M service is incorporated into the related E/M visit,” Holle adds.

That’s part of the reason why, while 99421-99423 are Column 2, or component, codes to 99201-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …), the edit pairs all have 0 modifier indicators, meaning that you cannot use an NCCI-associated modifier to unbundle the services, with the exception that 99422 and 99423 are not paired with 99201-99205. For the established patient E/M codes, things are a little more complicated, as 99421-99423 are not paired with 99211, while only 99421 is paired with 99212.

Conversely, when 99422-99423 are the column 1, or comprehensive, codes, NCCI has only paired them with 99201, 99211, and 99212, with each pair having a 0 modifier indicator. However, as a column 1 code, 99421 only has a 0 indicator with 99211. The codes are not paired with any of the other 99201-99215 codes.

Why? “When 99421-99423 are paired up with the 99201-99215 codes, some edit pairs have the 99421-99423 codes in Column 1, and some edit pairs have them in Column 2,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “I believe CMS has decided which code is the Column 1 code in any given combination based on which of the two codes in the pair has a higher work relative value unit [RVU], indicating a more extensive service,” Moore continues.

Pro coding tip: Despite these exceptions, there are still many instances when 99421-99423 and 99201-99215 are not code pairs. This means that you will be able to claim an online digital E/M with an office visit on the same date of service. To do so, you must be able to justify that the two services are not related in any way.

For example, “if a child is seen for a cold, then a parent emails the pediatrician later in the day wondering what to do about an exacerbation of the child’s asthma that occurred right after the visit, you may well be able to claim both services,” notes Holle. Just make sure you provide appropriate documentation to justify each of the services if they occur on the same day.

… and Look to Descriptors to Understand Nonphysician Digital E/M Pairs

The other new set of digital online E/M service codes ­— 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) and 98971 (… 11-20 minutes), and 98972 (… 21 or more minutes) — are strictly for use with qualified nonphysician health care professionals (QNHPs) physical and occupational therapists, dieticians, speech-language pathologists, or clinical social workers (CSWs), depending on licensing and state, CMS, or payer guidelines. 

“Because those practitioners can’t report 99201-99215, there is theoretically no reason to have edits involving both sets of codes,” says Moore. So, there is no reason why, under the right circumstances, you can’t claim an office E/M with one of these services when a physician provides an office visit and a QNHP provides the online digital E/M service.

But 98970-98972 are a part of numerous other code pairs. Mostly, they are Column 2 codes with other non-face-to-face services including 99421-99423 and 99441-99443 (Telephone evaluation and management service by a physician or other qualified health care professional …), where they have a modifier indicator of 1 (meaning that you can use a modifier to unbundle the services), and 99446-99449 (Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician …), where they have a modifier indicator of 0.

For the full list of the current PTP edits, go to  www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Version_Update_Changes.html

and download the zip file “Quarterly Additions, Deletions, and Modifier Indicator Changes to NCCI edits for Physicians/Practitioners Effective January 1, 2020.”