Primary Care Coding Alert

Know how these April CCI edits could affect your practice.

The Centers for Medicare and Medicaid Services (CMS) just made the next round of Correct Coding Initiative (CCI) edits available, and as usual, the updates will have some impact on primary care coding.

The good news is that there are only a handful of additions that could affect your reporting. And all the deletions are simply the reverse of additions to two prolonged evaluation and management (E/M) services.

So, here is your first look at some of the edits that took effect on April 1, along with expert insight explaining why CMS is making the changes and whether they will affect your reporting.

Physiologic Data Collection Now Bundled into Care Management Codes

The first change that could have an impact on your practice is the bundling of 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) into a number of care management services, including:

• 99484 - Care management services for behavioral health conditions ...
• 99487 - Complex chronic care management services ... 60 minutes of clinical staff time ... per calendar month
• +99489 - ... each additional 30 minutes
• 99490 - Chronic care management services ...
• 99492 - Initial psychiatric collaborative care management, first 70 minutes in the first calendar month ...
• 99493 - Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month ...
• +99494 - ... each additional 30 minutes in a calendar month ...
• 99495 - Transitional Care Management Services ... Medical decision making of at least moderate complexity during the service period Face-to-face visit, within 14 calendar days of discharge
• 99496 - Transitional Care Management Services ... Medical decision making of high complexity during the service period Face-to-face visit, within 7 calendar days of discharge
• G0506 - Comprehensive assessment of and care planning for patients requiring chronic care management services ....

As far as changes go, "this one seems to make sense," according to Suzan Hauptman, MPM, CPC, CEMC, CEDC, AAPC Fellow, senior principal of ACE Med in Pittsburgh. "Care management includes a review of the recent test results," Hauptman goes on, "so bundling this review into care management for the betterment of the patient's treatment plan follows a natural course."

Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians, agrees with Hauptman about the logic of the change. "The guidelines preceding the care management codes in CPT^® state 'Care management services include . . . analysis of data (99090, 99091), . . . and, if performed, these services may not be reported separately during the month for which 99487, +99489, 99490 are reported,'" Moore observes, concluding that "I think CMS did this to be consistent with CPT^®."

CMS Flips Prolonged Services Code Bundles

The next change sees CMS flipping the status of 99358 (Prolonged evaluation and management service before and/or after direct patient care; first hour) and its add-on, +99359 (... each additional 30 minutes ...) from Column 1 to Column 2 in edits with three other codes. Prior to April 1, these prolonged E/M codes were Column 1 codes into which the following services were bundled:

• 99408 - Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes
• 99409 - ... greater than 30 minutes
• 99463 - Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant admitted and discharged on the same date.

Now, the opposite is true, and 99358/+99359 are Column 2 codes bundled into 99408, 99409, and 99463.

The reasoning behind this change, however, is less clear.

Hauptman feels the change in 99463 could be because the code is "a per-day service regardless of the amount of time," whereas 99358/+99359 are time-based codes. So, Hauptman speculates, "it would make sense" to reverse the bundle.

As for the other codes, it may be that the bundle reversal puts the reason for the patient's visit ahead of the E/M service. If the main reason for the visit is counseling around alcohol or substance abuse, then having 99408 or 99408 as the first edit in the pair would also make sense.

Edits Also Affect 2 HCPCS Codes

Finally, two other changes to take note of involve two HCPCS codes: G0515 (Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes) is now bundled into 99455 (Work related or medical disability examination by the treating physician ...) and 99456 (Work related or medical disability examination by other than the treating physician ...); while 96127 (Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument) will be bundled into G0444 (Annual depression screening, 15 minutes).

In these instances, CMS's intent seems relatively straightforward. Now, two component services (skills development and a behavioral assessment inventory) are bundled into larger, more comprehensive services (an exam and a screening, respectively).

(To download the full list of CCI edits for this quarter, go to https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Version_Update_Changes.html).