Primary Care Coding Alert

How much do you remember about these big changes from the last 12 months?

Like any year, 2021 has seen its fair share of changes, especially in the world of coding. Inevitably, it takes some time to process them all.

So, to help, we’ve recapped three of the biggest changes in CPT^® and ICD-10 coding practices from 2021, so you can hit the ground running in 2022.

Refresher 1: PCM and How it Can Be Implemented in Your Practice

Principal Care Management (PCM) is a new kind of care management designed for “one complex chronic condition ‘expected to last at least 3 months placing the patient at significant risk of hospitalization, acute exacerbation/ decompensation, functional decline, or death’” according to Samuel L. “Le” Church, MD, MPH, CPC, CPC-1, CRC, FAAFP.

Beginning Jan. 1, 2022, you will be able to report it using 99424 (Principal care management services, … first 30 minutes provided personally by a physician or other qualified health care professional, per calendar month), +99425 (… each additional 30 minutes …), 99426 (Principal care management services … first 30 minutes of clinical staff time directed by physician or other qualified health care professional, per calendar month), and +99427 (… each additional 30 minutes …).

To implement PCM into your practice, you need to ensure the following criteria are met:

• The services are provided by physicians or other qualified health care professionals (QHPs) such as physician assistants (PAs), certified registered nurse practitioners (CRNPs), or clinical nurse specialists (CNSs), or clinical staff under the direction of a physician or other QHP, such as medical assistants, licensed practical nurses (LPNs), registered nurses (RNs), and others depending on the scope of practice as defined by state law;
• The physician or QHP develops, monitors, or revises a disease-specific care plan and oversees “frequent adjustments in the medication regimen and/or the management of the condition is unusually complex due to comorbidities”;
• The services require “ongoing communication and care coordination between relevant practitioners furnishing care” and follow CPT^®’s office requirements for care management services, including 24/7 patient access to physicians or other QHPs, use of an electronic health record (EHR) system, and a dedicated care team member responsible for providing continuity of care.

Refresher 2: Difference Between Medicare and CPT^® Prolonged Services Calculations

To understand how and why Medicare counts prolonged services differently from CPT^®, you must first understand how +99417 (Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required time of the primary procedure which has been selected using total time … each 15 minutes of total time (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services)) (emphasis added) and its Medicare counterpart G2212 (Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services) …) (emphasis added) work in conjunction with 99205 (Office or other outpatient visit for the evaluation and management of a new patient … 60-74 minutes of total time is spent on the date of the encounter) and 99215 (Office or other outpatient visit for the evaluation and management of an established patient … 40-54 minutes of total time is spent on the date of the encounter).

Simply put, CPT^® tells you to begin calculating prolonged services after the level 5 office/outpatient evaluation and management (E/M) goes beyond the minimum threshold for the codes (60 minutes for new patient visit 99205 and 40 minutes for established patient visit 99215), whereas Medicare tells you to begin after the maximum threshold for the level 5 office/ outpatient E/Ms — 75 minutes for 99205 and 55 minutes for 99215.

So, if your provider saw an established patient for 90 minutes, you would bill 99215 for the first 40 minutes, and +99417 x 3 for the additional 50 minutes to payers following CPT^® guidelines. Under Medicare guidelines, however, you would bill the same encounter with 99215 for the first 54 minutes and only two units of G2212, because CMS does not allow the G2212 to be used until 69 minutes have passed (i.e., 15 minutes beyond the 54 maximum for 99215). Adding another 15 minutes to 69 minutes would bring you to 84 minutes, which means you can report a second unit of G2212 but not a third.

Refresher 3: Changes in Requirements for Documenting Laterality and SDoH

Changes to ICD-10 guidelines 1.B.13 and 1.B.14, which took effect on Oct. 1, 2021, now enable you to document laterality, social determinants of health (SDoH), and blood alcohol level, “based on medical record documentation” from clinicians other than the patient’s provider

But you need to be careful doing this, because “while other clinicians may document the data points listed, the patient’s provider is still responsible for documenting the associated diagnosis, especially if there’s any question or conflict,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Example: A case manager in your practice documents in a patient’s record that the patient has been unemployed for some time. Even though your provider has not documented this, you may still go ahead and document Z56.0 (Unemployment, unspecified) in the patient’s record.