Primary Care Coding Alert

Once you’ve answered the quiz questions on page 27, compare your answers with the ones provided below:

Answer 1:
There are two main differences between 99490 (Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored.) and 99491 (Chronic care management services, provided personally by a physician or other qualified health care professional, at least 30 minutes of physician or other qualified health care professional time, per calendar month, with the following required elements …).

“The first difference between the codes that you should remember is the time requirement,” Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania, reminds coders. For 99491, you must be able to document that the chronic care management took at least 30 minutes. For 99490, the descriptor stipulates that the time spent in the management services must be “20 minutes or more.”

“The second difference is that 99490 is for chronic case management directed by a physician, whereas 99491 is care management personally provided by the physician,” says Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California, noting that the provider can also be a qualified health care professional (QHP) per the CPT^® descriptors.

Answer 2:
The answer to all these questions is, yes. New code 99454 (Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days) allows you to bill for the supply of a blood pressure monitor, pulse oximeter, or similar remote physiological monitoring (RPM) device.

Additionally, 99453 (Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment) allows for “the initial work associated with onboarding a new patient,” says Falbo, which includes “the set-up and education on the use of the new equipment,” according to Johnson.

Answer 3:
There are a number of major differences between 99091 (Collection and interpretation of physiologic data (eg, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time, each 30 days) and 99457 (Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month).

First, the clinical responsibilities are distinct. Code “99457 is for the management of the patient and time spent communicating with the patient or caregiver, whereas with 99091 the provider must collect, review, and provide a written interpretation of the data,” notes Johnson.

Then there are differences in the time needed to document the service and the frequency with which you can report the code. For 99091, you must be able to document that the collection and interpretation of the data took at least 30 minutes. For 99457, the descriptor stipulates that the time spent in the management services must be 20 minutes or more.

For 99091, CPT^® added “each 30 days” to the end of the descriptor in its 2019 revision of the code to specify the frequency with which you can report the code. For 99457, you are able to report the code once “each calendar month.” “This makes 99457 much easier to track because it is based on a calendar month, not 30-day periods, which will more easily align with recordkeeping and claims submission,” Falbo cautions coders.

Finally, to report 99091, the provider must be “a physician or QHP.” For 99457, the descriptor allows for “clinical staff,” in addition to physicians and QHPs, to provide the service. So, you must make sure that “your practitioners are practicing in accordance with applicable state law and scope of practice laws, and that when you document 99091, 99457, 99490, and 99491, you are following the CPT® definition of QHP if a QHP is providing the service” Falbo adds.