Pulmonology Coding Alert

2016 has brought welcome changes for your practice.

If you thought that advance care planning pay would never materialize, thanks to the 2016 CPT^® updates, you actually can collect for the service. To find out how—and to discover other changes important to your practice—check out the following tips that healthcare consultant Jill M. Young, CPC, CEDC, CIMC, shared during her recent Coding Institute audioconference Pulmonary Updates and Changes for 2016.

1. Advance Care Planning Could Put $86 in Your Pocket

A major change that affects the Advance Care Planning codes—99497 and 99498—is the fact that they will now be payable under the 2016 Fee Schedule revision, Young advised. The codes, which mainly concern legal planning (medical power-of-attorney, etc.) and medical counseling, will pay approximately $86 for the initial 30-minute face-to-face visit (99497) and $75 for each additional 30-minutes (99498). The descriptors are as follows:

• 99497 – Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate
• 99498 – Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure).

 The providers can work with their patients to create end of life plans, keeping in mind the needs of the patient and his family. Young points out that the revised codes now allow for physicians, nurse practitioners, physicians’ assistants, and specialists to bill in both facility and non-facility settings. Last year, these codes were bundled as a part of an E/M visit and not separately billable. Being able to report the planning in addition to other services is a welcome boost to your bottom line.

“When documenting these services, the provider must document the time spent (a minimum of 16 minutes in order to report 99497; and a minimum of 46 minutes in order to report 99497 and 99498),” says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania. “Discussion details must be documented, as well as the patient’s response, even if the response is that the patient is undecided at the moment. 99497 is reported for each encounter that meets these requirements; 99498 cannot be reported without 99497. If your office is assisting the patient in filling out forms (not required, but it may occur), keep in mind that the provider and patient must utilize state-regulated forms.”

Keep an Eye on the Deductibles

Medicare deductibles are rarely met when patients come in for their January visits, but with the Part B deductible threshold rising, it’s best to wait and assess your patient’s situation before billing. Bill the patients appropriately once you know exactly what their liability is, as this will help you avoid having to process a refund and reassure older patients who are worried about the costs. 

These services can be provided in addition to most separately identifiable E/M services that a pulmonologist would provide. Modifier 25 would be added to the E/M service, when applicable.

2. CMS Reverts to Original Structure of 2014’s Incident-to Billing

New for 2016, CMS clarifies the incident-to guidelines once again. The “physician practitioner who bills has to be the supervising one, the one that’s in the office ... and we know for incident-to billing, the physician has to see the patient at intervals to indicate that they are involved actively in their care,” Young advised.

As with many other CMS policies, the incident-to billing rules are mandated by the states in which they are practiced and can be overruled by those states. Be sure to check your state’s guidelines before reporting these services.

Pohlig mentions the following “Incident-to” reminders:

• The individuals performing the “incident-to” service must be directly employed or leased by the physician practice/group/entity
• The services can only be performed in an “office” setting (POS 11)
• Services are limited by the state scope of practice
• Direct supervision must be provided by a physician during the time of service.

3. New Bronchoscopy Codes for 2016 Combine With EBUS

Effective Jan. 1, 2016, CMS introduced new bronchoscopy codes for Endobronchial Ultrasound Guidance System (EBUS).

A Glance at 3 Things That Deserve Your Attention

POS 19 and POS 22: The wording of place of service codes POS 19 (Off Campus-Outpatient Hospital) and POS 22 (On Campus-Outpatient Hospital) stand revised.

Global Days: Lack of global days for pulmonary procedures in 2016 still a debated issue, CMS may materialize solutions in future.

Prolonged Service Codes: CMS has revised prolonged service codes 99354-99355 and 99415-99416 in reference to patient contact and care. Heed the new emphasis on what “clinical staff” means and the proper documentation of time spent with patients. 

“31620 has been deleted, and replaced with three new EBUS codes,” says Pohlig. Two of the three primary codes focus on “transtracheal and/or transbronchial sampling (eg, aspiration[s] /biopsy[ies]),” with 31652 concerning “one or two mediastinal and/or hilar lymph node stations or structures” and 31653 centering on “three or more.” Young advises that the third code, 31654, is an add-on transendoscopic code to identify EBUS used to access peripheral lesions.

“CMS erroneously created CCI edits bundling the EBUS codes into other bronchoscopy codes,” clarifies Pohlig. “This was brought to their attention, and they corrected this error with the quarterly CCI updates in April 2016. CMS suggested that any denied services should be re-submitted.”

Lastly, in coordination with 31652, 31653, and 31654, CMS has revised the sedation codes to accommodate the industry’s use of EBUS. Young explains, “31632 and 31633 are companion codes for transbronchial lung biopsy and transbronchial needle aspiration that both now have moderate sedation indicators in the CPT^® book.”

4. Changes to ‘Inhalation Treatment’ Clarify Past CMS Discrepancies

The big news concerning inhalation treatment this year is the revision of 94640 (Pressurized or non-pressurized inhalation treatment for acute airway obstruction ...). The new guidelines more clearly differentiate 94640 from related codes.

“94060 is our bronchodilator responsiveness code,” Young says. “94070 is for bronchospasm and provocation evaluation. 94400 is the breathing response to CO2. So we’re not to report this [94640] in conjunction with those codes.”

Young believes that CMS is “long overdue” in revising these codes and reminds providers to watch for using modifier 76 (Repeat procedure or service by the same physician or other qualified health care professional), should more than one treatment be administered or last longer than expected.

5. CCM Nails Down ‘Clinical Staff’

The who, what, when, and where of chronic care management (CCM) codes are the bones of this year’s updates. Young clarifies that under the new Medicare update, “clinical staff” now refers to licensed personnel only and differs from the terminology in the beginning of the CPT^® handbook.

This varies by state and also impacts transitional care because the two codes both have billing limitations in the same month which can overlap. If transitional care management is billed at the beginning of the month, it “contaminates” the month, Young says, blocking CCM codes from being billed.

“Transitional care management is a rolling 30 days. Chronic care management is a month,” she adds.

The road ahead: “In order to implement these updates successfully, review the services that are affected by revisions and deletions within your practice,” says Pohlig. “Communicate this information to your practice providers and staff to ensure that all personnel are notified. Discuss any new service opportunities (such as advance care planning) with the lead physician in the practice to determine if they apply to your patients. If so, then gather information to assist the physicians in capturing the new service via templates, forms, or documentation requirements. Prioritize addressing the various changes arising from the CPT^® updates according to their risk and liability. Any changes that could impede appropriate reporting of services such as ‘incident-to’ changes or coding clarifications should be handled first; followed by revenue opportunities.”