Pediatric Coding Alert

Hint: Keep your eyes on the 2021 PFS.

Preparing for major changes to office or outpatient evaluation and management (E/M) codes. Dealing with the COVID-19 public health emergency (PHE).

This was a momentous year in coding, and many of 2020’s biggest coding developments will continue to unfold in 2021. Here’s how.

January: The Office and Outpatient E/M Overhaul Begins

We began 2020 preparing for the major changes to E/M codes 99202-99205/99212-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …) and 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional …) that will take place on Jan. 1, 2021. 

To recap: You will have the option to report these codes based on total physician/other qualified healthcare professional time on the same date of service (which could include test result reviews, counseling patients or patients’ families, documenting in the medical record, and consulting with other healthcare professionals) or the level of medical decision making (MDM) per the new guidelines found at www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf.

But remember. Some things won’t be changing next year ….

2021 Takeaway 1: “Right now, these changes apply to office and outpatient visits only,” Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania reminds coders. All the other E/M services you report will stay the same in 2021.

2021 Takeaway 2: For these codes, even though “the amount of history or number of elements examined will not determine the overall E/M level of service, a history and physical examination will still need to be performed and documented if medically appropriate,” explains Falbo.

March: The PHE Changes the Telehealth Game

On March 31, 2020, the Centers for Medicare & Medicaid Services (CMS) outlined the first of many major changes to healthcare due to the COVID-19 public health emergency (PHE). Medicare began paying for 99441-99443 (Telephone evaluation and management service …) and lifted geographic restrictions on telehealth, allowing services to be “furnished by physicians and other practitioners to patients located anywhere in the country, including in a patient’s place of residence.”

Additionally, Health and Human Services (HHS) Office of Civil Rights (OCR) changed the definition of “interactive telecommunications system” to include mobile phones and waived Health Insurance Portability and Accountability Act (HIPPA) restrictions to allow physicians to use “everyday communications technologies, such as FaceTime or Skype … during the PHE,” providing the communication is both aural and visual.

2021 Takeaway 3: CMS updated the telehealth list several times during 2020 and may continue to do so in the new year. So, it is important that you check the list by going to www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes periodically and watch the 2021 Medicare Physician Fee Schedule (PFS) final rule to see which changes will become permanent.

2021 Takeaway 4: In October, Health and Human Services (HHS) renewed the PHE effective October 23. This means the all the current PHE waivers and regulations will continue until at least January 2021. Keep your eyes on the HHS PHE website at www.phe.gov/emergency/news/healthactions/Pages/default.aspx for further updates.

August: ICD-10 Gets a New Chapter and New Guidelines

The addition of Chapter 22 to ICD-10-CM, Codes for special purposes (U00-U85), was made permanent, and the new chapter established guidelines for using new codes U07.0 (Vaping-related disorder) and U07.1 (COVID-19), which became effective on Oct. 1, 2020.

For U07.0, guidelines tell you to use the code on its own “for lung injury due to vaping”; use an additional code to identify manifestations; not to code separately such vaping-associated signs and symptoms as cough or shortness of breath “when a definitive diagnosis has been established”; and to code gastrointestinal symptoms when applicable.

And for U07.1, those guidelines tell you to list the code as the principal/first-listed diagnosis and code for both respiratory and non-respiratory manifestations; use Z20.828 (Contact with and (suspected) exposure to other viral communicable diseases) “for asymptomatic individuals with actual or suspected exposure to COVID-19” and “for symptomatic individuals with actual or suspected exposure to COVID-19” when “the infection has been ruled out, or test results are inconclusive or unknown.”

2021 Takeaway 5: Though you won’t have to worry about it in 2021, ICD-11 is coming. AAPC believes the earliest you may be using ICD-11 would be in 2025 for reporting morbidity, and that the clinical modification (CM) version won’t appear any time before 2027.

Even so, you’ll want to glance at the National Committee on Vital and Health Statistics (NCVHS) website (ncvhs.hhs.gov/) occasionally next year to see when this big change will take place.

September: CPT^®, CMS at Odds Over Prolonged 99205/99215 Service

CPT^®’s addition of +99417 (Prolonged office or other outpatient evaluation and management service(s) …; each 15 minutes …), to take effect on January 1, will let you count additional total time on the date of service in 15-minute increments over the designated times for 99205 (74 minutes) and 99215 (54 minutes) when you select these E/M codes on the basis of time.

However, in the 2021 PFS proposed rule, “CMS’ instructions are not the same as the CPT^® instructions. CMS is proposing to permit +99417 only when the maximum times of 99205 or 99215 have been exceeded by 15 minutes, or when the times for the codes hit 89 minutes or 69 minutes, respectively,” explains Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. 

2021 Takeaway 6: Wait for the upcoming 2021 PFS final rule to see if the discrepancy between CMS and CPT^® times for implementing +99417 gets resolved.

2021 Takeaway 7: Remember that the “old” prolonged care codes (+99354-+99359) should still be used in 2021, but not with any of the sick office visit codes 99202-99215.