Pediatric Coding Alert

How many of these changes can you recall?

The world certainly has seen a lot in the last year, and so, too, has the world of coding. As is always the case, it takes some time to process it all.

Calendar year (CY) 2023 has seen its fair share of changes, so to help you keep up to date, we’ve recapped four big 2023 updates, so you can hit the ground running in 2024.

Takeaway 1: Time to Change E/M Visit Calculations

While technically a change that won’t take effect until Jan. 1, 2024, this recently announced update is worth talking about now to give you time to prepare. CPT^® has removed the time ranges from both the new and established office/outpatient E/M code descriptors and replaced them with a single time that “must be met or exceeded.”

For example, 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making …) has a current time range of 15-29 minutes. However, the provider soon must meet or exceed 15 minutes of total service time on the date of the encounter before you can bill this code by time.

The new 2024 CPT^® code book will feature revisions to all the office/outpatient evaluation and management (E/M) codes. Here is a side-by-side comparison:

Essentially, “this doesn’t really change how the codes are used, but listing the minimum time instead of a range for each code is probably going to be easier to follow,” says Kelly Loya, CPC, CHC, CPhT, CRMA, CHIAP, associate partner at Pinnacle Enterprise Risk Consulting Services.

Remember: Total time will still include face-to-face time as well as time the physician and/or qualified healthcare professional (QHP) personally spent on the patient’s care on the day of the encounter (i.e., total time on the date of the encounter). But “it does not include time spent in the performance of separately reported services,” explains Jacob Swartzwelder, CPC, CRC, CIC, CEMC, AAPC Approved Instructor, managing director at Compliant Approach Partners, LLC in Las Vegas, NV during his session “E/M Audits for Primary Care” at HEALTHCON Regional 2023 in Washington, DC. Counting the same time toward an E/M service and a separately reported service would be double-dipping.

Note: CPT^® will not be changing the descriptor to 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), which you may continue to bill for established patients receiving E/M services from a clinical staff person other than a physician or QHP. The code will also continue to require no level of medical decision making (MDM) or total time for you to document.

Takeaway 2: Remember to Enter These 173 New Foreign Body Codes

In an effort to more accurately and completely document the specific foreign body being reported, ICD-10 created W44 (Foreign body entering into or through a natural orifice).

The codes are organized by the object’s material:

• W44.A- (Battery entering into or through a natural orifice)
• W44.B- (Plastic…)
• W44.C- (Glass…)
• W44.D- (Magnetic metal…)
• W44.E- (Non-magnetic metal…)
• W44.F- (Objects of natural or organic material…)
• W44.G- (Non-organic objects…)
• W44.H- (Sharp objects…)
• W44.8- (Other foreign body…)
• S44.9- (Unspecified…)

Note: Each of these codes requires a 7th character representing the encounter type as follows:

• A: initial encounter
• D: subsequent encounter
• S: sequela

For a more complete list of these codes, refer to Pediatric Coding Alert Volume 26 Number 9.

Takeaway 3: Add These New Z Codes to Your Reporting

Starting Oct. 1, 2023, ICD-10 also added a handful of useful Z-codes (including several social determinants of health (SDoH) codes), many of which expand on a bunch that they added back in 2022.

Some of the new codes affect the different ways you can report the intricacies of child-guardian relationships that may impact the child’s health:

• Z62.23 (Child in custody of non-parental relative)
• Z62.24 (Child in custody of non-relative guardian)
• Z62.823 (Parent-step child conflict)
• Z62.83- (Non-parental relative or guardian-child conflict)
• Z62.831 (Non-parental relative-child conflict)
• Z62.832 (Non-relative guardian-child conflict)
• Z62.833 (Group home staff-child conflict)
• Z62.892 (Runaway (from current living environment))

Note: Along similar lines of child welfare, ICD-10 also added Z02.84 (Encounter for child welfare exam).

ICD-10 also added six new codes to the Z91.A- codes to address caregiver noncompliance in greater detail:

• Z91.A41 (Caregiver’s other noncompliance with patient’s medication regimen due to financial hardship)
• Z91.A48 (Caregiver’s other noncompliance with patient’s medication regimen for other reason)
• Z91.A51 (Caregiver’s noncompliance with patient’s renal dialysis due to financial hardship)
• Z91.A58 (Caregiver’s noncompliance with patient’s renal dialysis for other reason)
• Z91.A91 (Caregiver’s noncompliance with patient’s other medical treatment and regimen due to financial hardship)
• Z91.A98 (Caregiver’s noncompliance with patient’s other medical treatment and regimen for other reason)

Takeaway 4: Expect Another Delay in the Anticipated Split/ Shared Visits Update

Remember when the Centers for Medicare & Medicaid Services (CMS) finalized the implementation of a new split/shared policy back in 2022? Essentially, it stated that the provider who administers the substantive portion of the visit, whether it’s the physician or the nonphysician practitioner (NPP), bills for the E/M services. CMS ended up delaying this policy update in the CY 2023 Medicare Physician Fee Schedule (MPFS) final rule.

Many have opposed the change since CMS first proposed the policy, so this delay created more time for stakeholder feedback and policy revisions.

Well, CMS has proposed to extend the delay and keep the current split/shared rules for a little bit longer, with a start date for the new policy now slated for Jan. 1, 2025.

As you know, pediatric coders don’t usually have to deal directly with Medicare as a payer, but the entity undeniably sets a standard that many commercial payers end up following. So, this CMS update, whenever it takes effect, will undoubtedly directly impact medical coders in a number of specialties.