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Primary Care Coding Alert

2013 AMA Symposium Update:

Get the Scoop on Transition Codes, PCIP Pay Requirements for FPs

Published on Tue Dec 04, 2012

Caution: Missing primary care designation could wreck your Medicare pay. .

Family practitioners can look forward to a continued cash flow from the primary care incentive program, more inclusive language in CPT® codes, and new codes for transitional care.

So said speakers at the American Medical Association's (AMA) annual CPT® and RBRVS Symposium, held Nov. 14-16 in Chicago, with presenters sharing the latest news on fee schedules, new codes for 2013, and more.

Don't Fret Over Far-Reaching Terminology Change

The most widespread changes throughout CPT® 2013 -- the switch to more inclusive or provider-neutral language -- shouldn't be difficult for physician practices to put into place.

"The concepts are pretty straightforward," said Richard Duszak, Jr., M.D., an AMA CPT® Editorial Panel member and practicing radiologist. "There's been an evolution in CPT® for how codes report services by non-physicians."

Result: Hundreds of codes were revised for 2013 to include "provider neutral language." Codes throughout the book have replaced designations of "physician" with "individual" or "qualified health care provider."

Exception: A few codes retained the "physician" language, such as those related to skilled nursing facility admissions, because regulations require that a physician admit the patient.

"CPT® is not the turf police," Duszak said. "We're focusing on the services provided and recognize that sometimes professionals other than physicians are qualified to provide some services. As a nationally recognized reporting system, it's important for CPT® to maintain provider neutrality."

Watch Your Mail for PCIP Checks

CMS will continue the primary care incentive program (PCIP) through 2015. The agency distributed approximately $560 million to providers in 2011 through

PCIP, according to Kathy Bryant, deputy director of the department of physician services at CMS.

Bonus: Providers don't need to apply for participation. CMS reviews providers' records and automatically sends payments to those who qualify.

Big caution: "The main thing you need to worry about is your physician's Medicare specialty designation," Bryant cautioned. "He must have the primary care specialty designation in CMS records, or he won't receive payments. He may have switched from ER to primary care years ago, but he won't get paid if his CMS designation still says ER."

Prepare Now for New Transitional Care Codes

CPT® 2013 introduces two new codes for transitional care management (TCM) services:

  • 99495 -- Transitional care management services with the following required elements: communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge; medical decision making of at least moderate complexity during the service period; face-to-face visit, within 14 calendar days of discharge
  • 99496 -- ... medical decision making of high complexity during the service period; face-to-face visit, within 7 calendar days of discharge.

The codes are meant to represent situations when a physician oversees an established patient whose medical/psychosocial issues require moderate to high complexity medical decision making (MDM) during the shift from a healthcare facility setting back to the patient's community (home) setting. Another key to determining whether to report 99495 or 99496 hinges on timely follow-up -- how many days pass between the patient's discharge and when the physician is able to see the patient.

Learn more: Watch for a through explanation of the TCM codes and another new category, complex chronic care coordination services (CCCC) in next month's issue of Family Practice Coding Alert.

Hold On for More Payment News

Medicare rates are scheduled to take a 26.5 percent hit in 2013 unless Congress takes action to avert the cut.

"The President's budget calls for an aversion of the cut and a permanent fix," Bryant told Symposium attendees. "They seem to be working on it, but we haven't heard yet where it's going."

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