cpt coding 2017: basic principles and practice principles and practice peter a. hollmann md. peter...

CPT Coding 2017:

Basic Principles and Practice

Peter A. Hollmann MD

Peter Hollmann, MD

Has no affiliation with, or financial interest in, any

commercial interest that may have direct interest in

the subject matter of his presentation.

Speaker Disclosures:

Agenda Topics

1. Coding in Context

2. What is new in 2017

3. Evaluation & Management (E/M) Services

4. Chronic and Transitional Care Management

5. Preventive Services

6. Other Important Codes and Rules

7. Cases

Utility of Coding

• Billing and Payment

• Risk Adjustment (HCC/RAF)

• Productivity Assessment (RVUs)

• Predictive Modeling

• Quality Measurement and Improvement

• Public Health

• Health Services and Other Research

Key Systems

• CPT (AMA)• Procedures

• RUC Valuation

• Used to report Professional Services and by Facilities for

Outpatient Services.

• ICD-10 (WHO, CMS and NSHS)• Diagnoses ICD10-CM for all reporting

• Procedures ICD10-PCS For Inpatient

• HCPCS Level II (CMS)• G codes, J codes for drugs, supplies, specified Medicare

services and Quality Reporting

• Place of Service

Payer Policies Matter

• Medicare is not the only payer

• Medicare Advantage (Part C) matches BENEFITS, not

PAYMENTS

• Fee schedules differ by payer, product etc.

• Claims edits enforce rules

• CCI (bundled, mutually exclusive)

• Global periods

• Payment/coverage can vary by site of service, provider type,

diagnosis

• Modifier acceptance and requirements

• LCD/NCD and local contractor policies

Important Caveats

• Do not undercode or upcode – know your pattern/profile

• Get paid for what you do!• But sometimes you will not

• Billing rules seem like the tax code – variability, risk/reward• Documentation supports coding, does not define it

• Medical necessity first, then documentation

• Insurance does not cover everything – you can charge for non-covered services (ABN)

• Pay attention to your charges – you get paid the lesser of charge or allowance

• CMS does not always follow CPT

Profile Pattern

0

20,000

40,000

60,000

80,000

100,000

120,000

99211 99212 99213 99214 99215

Established Patient Office 2016 Medicare (1000)

CPT

AGS Advisor

Robert A. Zorowitz MD

CPT

• Updated annually to reflect changes in medicine

• Organized by body system – logical sequence in general

• Evaluation & Management section

• Modifiers

• Clinical examples (early 1990’s)

• Unlisted procedures (select only accurate codes)

Medicare

• Proposed Rule July

• New codes and proposals for 18 months later

• Final Rule November and Par Status

• The payments and rules on new codes

• The time to determine your status in Medicare

• HCPCS Codes Quarterly, but main changes effective

January 1

• Codes semi organized

• Official Education resources: MedLearn Matters, Internet

Only Manuals

• Benefits are Statutory

• ACA brought more logic eg USPSTF

Participation Options

Par: 100% PFS less copay and deductibles

Nonpar/accept assignment: 95% less copay and deductibles

Nonpar/ do not accept assignment: 115% of 95% (109.25%) and you must collect from patient

Opt out: neither provider nor beneficiary get Medicare funds

2017 Changes

1. Cognitive Impairment Assessment and Care Plan Services

2. Non-Face-To-Face Prolonged Evaluation & Management (E/M) Services

3. Chronic Care Management

4. Comprehensive Assessment & Care Planning

5. Behavioral Health Integration (BHI) Care Management

6. Psychiatric Collaborative Care Management Services

Annually check for coding, fee and benefit changes and decide participation status

Evaluation and Management (E/M)

• Place/type of service: eg office, hospital, NF

• Key elements: History, exam, complexity of medical

decision making

• Contributory: time, nature of presenting problem

• Select a level: Some services require all three

components, some only two

• Definitions and documentation criteria Does it take a

scorecard?

99214 (DGs)

Hx Detail 4HPI 2-9 ROS

1/3 PFSH

PE Detail 6 Organ 2 each

2 organ 6 each

MDM Mod Mult Diags

Mod Data

Mod Risk

TIME 25

KEY 2/3

Documentation Guideline-General

• Support Clinical Care

• Why is the patient present?

• What history and exam were performed?

• What were your thoughts?

• What do you plan to do/did you do?

Credit is given for history when patient/surrogate cannot provide eg coma

Extent of History (CPT)

•Problem Focused: chief complaint; brief history of present illness or

problem

•Expanded problem focused: chief complaint; brief history of present

illness; problem pertinent system review

•Detailed: chief complaint; extended history of present illness; problem

pertinent system review extended to include a review of a limited number

of additional systems; pertinent past, family, and/or social history directly

related to the patient’s problems

•Comprehensive: chief complaint; extended history of present illness;

review of systems which is directly related to the problem(s) identified in

the history of the present illness plus a review of all additional body

systems; complete past, family, and social history

CPT® is a registered trademark of the American Medical Association. CPT copyright 2016 AMA. All rights reserved.

1997 DGs for History

Extent of Examination (CPT)

Problem focused: a limited examination of the affected body area or

organ system

Expanded problem focused: a limited examination of the affected body

area or organ system and other symptomatic or related organ system(s)

Detailed: an extended examination of the affected body area(s) and other

symptomatic or related organ system(s)

Comprehensive: a general multi-system examination or a complete

examination of a single organ system Note: preventive medicine

evaluation and management service is multi-system, but its extent is

based on age and risk factors identified


Medical Decision Making (CPT)

• Medical decision making refers to the complexity of

establishing a diagnosis and/or selecting a management

option as measured by:

• the number of possible diagnoses and/or the number of

management options that must be considered;

• the amount and/or complexity of medical records,

diagnostic tests, and/or other information that must be

obtained, reviewed, and analyzed; and

• the risk of significant complications, morbidity, and/or

mortality, as well as comorbidities, associated with the

patient’s presenting problem(s), the diagnostic

procedure(s) and/or the possible management options.


MDM (CPT) cont’d.

• Four types of medical decision making are recognized:

straightforward; low complexity; moderate complexity;

and high complexity.

• To qualify for a given type of decision making, two of the

three elements in the following table must be met or

exceeded.

• Cormorbidities/underlying diseases, in and of

themselves, are not considered in selecting a level of

E/M services unless their presence significantly

increases the complexity of the medical decision

making.


MDM (CPT) cont’d.


CMS Table of Risk

Contractor Guidelines- Trailblazer

• Patient Condition (Medical Necessity) determines

H/PE/MDM and, assuming you provide appropriate care,

determines code

• Use Level 4 or 5 ONLY IF

• 3 or more problems managed OR

• A problem had 50%+ chance of worsening, death or

disability

• Use Level 5 ONLY IF

• 4 or more problems managed OR

• A problem has 50%+ chance of worsening, death or

disability

99214 Assembled


E/M Made Easy

• 99211 – Not seen by Physician or NPP

• 99212 – Minor problem, probably did not need to be seen

• 99213 – Stable problem

• 99214 – The typical multi-morbid

• 99215 – Time based or warranted complete re-evaluation

Time


Other Rules of E/M

New (vs. established): new or not seen in 3 years, or if a group, it is a new/different specialty (be sure you are a geriatrician to payer)

Consults: requested by a physician or other appropriate source (not patient or family) with written report back

Consults can be done by you on your patients (ER, pre-op)CMS does not recognize Consult Codes

Domicilliary Care is not Home Care

Observation care/same day dischargeReport OBS if same day discharge or facility designates OBSCMS expects >8 hrs for combined code

Preventive Medicine (99381 – 99397) is non-covered and billable to the beneficiary in traditional Medicare (be careful as most components are now covered).

Admissions services typically bundle OV, ER services (see CPT)Hospital Discharge and Nursing facility Admission may be reported same day

Modifiers, Global, CCI

• Certain services or procedures are considered part of

another service/procedure or in global period

• CMS (and many private payers) uses Correct Coding

Initiative claims systems edits

• Modifiers signal that CCI and other edits do not apply and

must be used properly or it may be fraud/abuse

Modifier 25

• Used for 000 Global

Procedures

• All procedures

include evaluation

Report All You Do !

• It is not just E/M or E/M-like G codes

• Procedures, tests

• Drugs and Supplies

• 99211

• Team members: Medical Nutrition Therapy, Health and

Behavior Assessments

• Critical Care

• Prolonged Services

But…………………………

• Get up and Go (97750)

• 15 minutes (8 minute threshold)

• Separate Report

• MMSE

• This is NOT CNS testing, it is PE

Noncovered Services

• Billing the patient for noncovered services is allowed

• Forms, legal matters

• Use approved Advance beneficiary notice if perceived as

covered, or covered, but not necessary

• “GY” not covered

• “GA” not necessary, ABN on file, written reason

supplied

• Is it always covered if medically necessary?

• If it is not paid, is it not covered and billable to patient?

Non Face to Face

• CMS has dramatically revised approach to care coordination,

but this is still a source of “uncompensated care”

• All services have “Pre” and “Post” work/time (pre-visit

planning, calls, lab follow-up, limited care coordination)

• Home Health Certification G0179, G0180

• Care Plan Oversite (HH, Hospice) G0181, G0182

• Care Management 99487, 99489, 99490

• Transitional Care Management 99495, 99496

• Prolonged Services W/O Direct Patient Contact 99358, 99359

• Family Psychotherapy (without patient present) 90846

Certification

• G0180Certification ($54.55) / 60d

• G0179Recertification ($41.99) / 60dG0179-80: Physician [re-certification] [certification] services for

Medicare-covered services provided by a participating home

health agency (patient not present), including review of initial or

subsequent reports of patient status, review of patient’s

responses to the Oasis assessment instrument, contact with

the home health agency to ascertain the initial implementation

plan of care, and documentation in the patient’s office record,

per certification period

• Documentation requirements not specified

• Not for NPP (but physician can use NPP eval)

• Date must match 485 start date

Face to Face Requirement

• F2F encounter 90 days prior start of home care or within

30 days after

• For the condition requiring home care

• Certification by a physician may be based on NPP

encounter

• Hospital of SNF physician can certify and transfer care

• Benefits Manual 100-2 Chapter 7; 30.5.1.1

Care Plan Oversight

• CMS rejected CPT due to time with nonprofessionals

• G0181 CPO-HHA ($109.46)

• G0182 CPO-Hospice ($110.18)

G0181-82: Physician supervision of a patient receiving Medicare covered

services provided by a participate [home health agency] [hospice](patient

not present) requiring complex and multidisciplinary care modalities

involving regular physician development and/or revision of care plans,

review of subsequent reports of patient status, review of laboratory and

other studies, communication (including telephone calls) with other health

care professionals involved in the patient’s car, integration of new

information into the medical treatment plan and/or adjustment of medical

therapy, within a calendar month, 30 minutes or more

CPO Rules

• Requirement for a timesheet documenting over 30

minutes exclusive of certification and discussion with

nonprofessionals (e.g., family) time

• No financial relationship with agency or hospice medical

director

• Only one physician, not in post op global if surgeon

• Prior face to face encounter (was 6 months now 90d)

• 30 minutes/month minimum

• MLPs using their number may bill for these services

• Box 23—agency number

• Only Hospice and Home Health Covered

• Use G codes, not CPT Codes

Hospice Rules

• Services require a GV or GW modifier

• GV Attending physician not employed or paid under

arrangement by the patient's hospice provider

• GW Service not related to the hospice patient's

terminal condition

“Deny claims for all other services related to the terminal illness furnished

by individuals or entities other than the designated attending physician,

who may be a nurse practitioner.”

Transitional Care Management

99495, 99496

• One face to face E/M type service and 30 days care

management

• Not for short-term follow-up clinic

• Must see within 14 days of discharge from inpatient

(hospital or SNF)

• Place of service is where seen

• MDM is for the whole 30 days, not the first F2F

encounter

• Effective 2017 may report on the date seen as the date

of service

• ICN 908628 (December 2016)

Transitional Care Management

• Interactive contact within 2 business days of discharge from

facility (two or more attempts)

• Face to face service within 14 days

• Medication reconciliation by the time of the F2F visit

• MDM of at least moderate complexity

• Documentation requirements:

• Date of discharge

• Date of interactive contact (or attempts)

• Date seen

• Complexity of MDM

TCM Code Selection

• Code determined by

• Medical Decision Making Complexity over the 30 days

• Days post discharge that face to face visit occurs

• New or Established, site of service does not matter

CY 2017 National Rates

CPT Code Short Description/CMS Posted Typical Time(s)

2017 NF MPFSNational Rate

2017 HOPPS National Rate

99214 E/M OP established Pt. MDM mod tohigh complexity, typically 25 min

$108.74 Status B

See visit G codes

G0463 = $106.56

99215 E/M OP established Pt. MDM high complexity, typically 40 min

$146.43 Status B

See visit G codes

G0463 = $106.56

99495 Trans Care Mgmt, 14 day Disch $165.45 $106.56

99496 Trans Care Mgmt, 7 day Disch $233.99 $106.56


E/M and TCM Services


CPT CodeShort Description/CMS Posted Typical Time(s)

2017 NF MPFS National Rate


G0179 Md recertification hha pt $41.99 Status M

G0181 Care Plan Oversight- HHA 30 days

$109.46 Status M

G0180 MD certification HHA patient, 60 days

$54.55 Status M

99214 E/M OP established Pt. MDM mod to high complexity, typically 25 min

$108.74 Status B

See visit G codes

G0463 = $106.56


HHA Care Plan Oversight (CPO)

TCM Exclusions and Allowed Separate

Reporting

• Only the first face to face is part of TCM. Other E/M is

separately reported and paid

• Discharge day services are allowed and paid, but cannot be

the “face to face” visit – it must be post transition

• May not report:

• ESRD

• CCM time within the 30 days

• CPO and Certification

99495 $165

99496 $234

99214+G0180+G0181 $273

99215+G0180+G0181 $310

99205+G0180+G0181 $330

Chronic Care Management


Policy Changes to Chronic Care

Management (99487, 99489, 99490)

• CMS changed 99487 and 99489 from “B” status to “A”

status

• This means they are now paid.

• Rules regarding initiating visit, electronic records and

consent were simplified by CMS


Policy Changes to Chronic Care

Management (99487, 99489, 99490)

ICN 909188

DECEMBER 2016


Who Qualifies for CCM


Table 11 – Summary of CY2017 CCM Service

Elements and Billing Requirements

• Initiating Visit—Initiation during an AWV, IPPE, or face-to-face E/M visit

(Level 4 or 5 visit not required), for new patients or patients not seen within

1 year prior to the commencement of chronic care management (CCM)

services.

• Structured Recording of Patient Information Using Certified EHR

Technology—Structured recording of demographics, problems,

medications and medication allergies using certified EHR technology. A full

list of problems, medications and medication allergies in the EHR must

inform the care plan, care coordination and ongoing clinical care.

• 24/7 Access & Continuity of Care—

• Provide 24/7 access to physicians or other qualified health care

professionals or clinical staff including providing patients/caregivers

with a means to make contact with health care professionals in the

practice to address urgent needs regardless of the time of day or day

of week.

• Continuity of care with a designated member of the care team with

whom the beneficiary is able to schedule successive routine

appointments.


Elements and Billing Requirements (cont.)

• Comprehensive Care Management—Care management for chronic

conditions including systematic assessment of the beneficiary’s medical,

functional, and psychosocial needs; system-based approaches to ensure

timely receipt of all recommended preventive care services; medication

reconciliation with review of adherence and potential interactions; and

oversight of beneficiary self-management of medications.

• Comprehensive Care Plan—

• Creation, revision and/or monitoring (as per code descriptors) of an

electronic patient-centered care plan based on a physical, mental,

cognitive, psychosocial, functional and environmental (re)assessment

and an inventory of resources and supports; a comprehensive care plan

for all health issues.

• Must at least electronically capture care plan information, and make this

information available timely within and outside the billing practice as

appropriate. Share care plan information electronically (can include fax)

and timely within and outside the billing practice to individuals involved

in the beneficiary’s care.

• A copy of the plan of care must be given to the patient and/or caregiver.



• Management of Care Transitions—

• Management of care transitions between and among health care

providers and settings, including referrals to other clinicians; follow-up

after an emergency department visit; and follow-up after discharges

from hospitals, skilled nursing facilities or other health care facilities.

• Create and exchange/transmit continuity of care document(s) timely with

other practitioners and providers.

• Home- and Community-Based Care Coordination—

• Coordination with home and community based clinical service providers.

• Communication to and from home- and community-based providers

regarding the patient’s psychosocial needs and functional deficits must

be documented in the patient’s medical record.

• Enhanced Communication Opportunities—Enhanced opportunities for the

beneficiary and any caregiver to communicate with the practitioner regarding

the beneficiary’s care through not only telephone access, but also through

the use of secure messaging, Internet, or other asynchronous non-face-to-

face consultation methods.



• Beneficiary Consent—

• Inform the beneficiary of the availability of CCM services; that only one

practitioner can furnish and be paid for these services during a calendar

month; and of their right to stop the CCM services at any time (effective

at the end of the calendar month).

• Document in the beneficiary’s medical record that the required

information was explained and whether the beneficiary accepted or

declined the services.

• Medical Decision-Making—Complex CCM services require and include

medical decision-making of moderate to high complexity (by the physician or

other billing practitioner).

Role of Physician or QHCP

Oversees the management and/or coordination of services, as needed, for:

• All medical conditions,

• Psychosocial needs and

• Activities of daily living

QHCP = Qualified Healthcare Professional

Plan of Care

• Must be documented and shared with patient and/or caregiver

• Based on physical, mental, cognitive, social, functional and environmental assessment

• Is a comprehensive plan of care for all health problems

Plan of Care Format:

• No Care Plan format, but must be in EMR

• EMR must have structured recording of

demographics, problems, medications, medication

allergies and the creation of a structured clinical

summary record. A full list of problems, medications

and medication allergies in the EMR must inform the

care plan, care coordination and ongoing clinical care

Plan of Care Includes:

• Problem list

• Expected outcome and prognosis

• Measurable treatment goals

• Symptom management

• Planned interventions

• Medication management

• Community/social services ordered

• How services of agencies/specialists unconnected to the

practice will be directed/coordinated

• Identification of the individuals responsible for each

intervention

• Requirements for periodic review

• Revision of the care plan, when applicable

Limitations

• May be reported only once per

calendar month

• May be reported by only the single

physician or QHCP who assumes the

care management role for the calendar

month

Time Requirements

• Face-to-face AND non-face-to-face time spent by clinical staff:• Communicating with patient/caregiver, other

professionals, agencies

• Revising, documenting and implementing care plan

• Teaching self-management

• Only count the time of one clinical staff member when two or more clinical staff members are meeting with the patient

• Do not count clinical staff time on day when physician or QHCP reports an E/M service

• CMS FAQs suggest it is related time not allowed

CMS Billing Requirements

• Inform beneficiary about availability of CCM

• Obtain written agreement to have services

provided – (Part B cost sharing)

• Document in record that CCM explained and note

decision to accept or decline

• Provide written or electronic copy of care plan

• Inform beneficiary of right to stop CCM at any time

• Inform beneficiary that only one practitioner can

furnish and be paid during a calendar month

Mutually Exclusive Services

Codes 99490, 99487, 99489 may not be

reported with:

• Transitional Care Management

(overlapping time)

• Care Plan Oversight

• Home Care Certification

(Do not report 99487, 99489, 99490 during the same month with 90951-

90970, 98960-98962, 98966-98969, 99071, 99078, 99080, 99090,

99091, 99339, 99340, 99358, 99359, 99363, 99364, 99366-99368,

99374-99380, 99441-99444, 99495, 99496, 99605-99607)


“Incident to” and site NF

Supervision does not need to be on-siteClinical staff do not need to be employeesDefinition of clinical staff not specified

Do need to have a relationship with billing provider and capacity to see patient

Despite CPT language, CMS allows this in NF per FAQs they issued – based on professional time meeting threshold.


Code Short Description/CMS Posted Typical Time(s)



G0507 Care manage serv minimum 2015 / 50 / 20 Total Time 85 min

$47.73 $25.20

99487 Cmplx chron care w/o pt vsit• Intra-Service 26 min (CPT minimum

staff 60 minutes)• Total 26 min

$93.67 $70.23

+99489 Cmplx chron care addl 30 min• Intra-Service 13 min (CPT minimum

30 minutes staff)• Total 13 min

$47.01 Status N Packaged

99490 Chron care mgmt srvc 20 min• Intra-Service professional 15 min• Total 15 min

$42.71 $70.23


Chronic Care Management Services


----NEW in 2017 $93.67

TIPS to Remember - CCM

• PCMH Medicare Demo patients ineligible (no “paying twice”)

• Remote monitoring is not CCM, but time reviewing info may be if CCM performed

• TCM and CCM same month OK of not overlapping time

• Also a list of other mutually exclusive services in CPT (and would include G code equivalents)(see CCI edits)

• Never count time twice!• Team conf. is one event• No time on day of E/M

Advance Care Planning (99497, 99498)


99497 = $82.90; 99498=$72.50

Advance Care Planning

• Separately payable with AWV; Use modifier -33 for no

cost sharing

• If done with AWV can be a team service

• CMS allows service to be “incident to” with some

significant direct supervision

• Separately payable with E/M (other than critical care);

use modifier -25


Advance Care Planning

• Standard CPT Time Rules (more than ½ way to

midpoint)

• Do not count any time that was part of determining level

of E/M as ACP time

• Does not require execution of a legally recognized

advance directive

• No predetermined frequency limits

• No specific special training/specialty restrictions


“Incident to and NPPs”

• General rule: “Incident To” Billing

Physician bills as the provider of service, even though major elements

of the service were performed by MLP. The payment amount is at the

physician level. Certain conditions must be met:

• MLP is employee

• Physician must provide “direct personal supervision.” In office

this means being immediately available in office; inpatient use

“shared visit” concept only. Physician must see patient if

inpatient. No “incident to” for SNF.

• Physician must initiate course of treatment and remain involved

in patient’s care.

• All the supervision rules are independent of any licensure

requirement, i.e., less restrictive licensure rules are irrelevant.


Reason is payment at 100% PFS

Delegation of Nursing Facility Services

• Physician may not delegate initial comprehensive

assessment in SNF

• RNP/CNS/PA may perform services prior to initial

comprehensive

• If state law allows, non facility level - employee may do initial

comprehensive for NF level

• Employee RNP/CNS may not certify SNF. All NF certification

rules up to state. (PAs now can certify)

• NO “incident to” or shared visits in SNF

• MedLearn Matters: SE0418


Prolonged Services (99354-99357)

• CMS First 29 minutes free

• Must be face-to-face (99354-99357)

• Office and inpatient settings have their own set

• “In addition to other services, including E/M at any level”

• May be appropriate when multiple hospital visits are

required as only one 99221-99233 is allowed


Preventive Services


https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html

Annual Wellness Visits


Preventive and Wellness Visits

• Initial Preventive Physical Exam (G0402)

• First 12 months of enrollment

• Initial Annual Wellness Visit (G0438)

• Only after 12 months of enrollment

• Subsequent Annual Wellness Visit (G0439)

• Is this a “yearly physical”?

• No

• May I do an “initial” service on an “established patient”

• Yes


IPPE (G0402)

• Once per life within 12 months of effective date of Part B

coverage. Fee $168.68

• Extensive: full H&P including modifiable risk factors,

depression, function (minimally: hearing, falls, ADL,

home safety, visual acuity, BMI, EOL)

• EKG (G0403-5) Not req’d.

• Education/counseling with written plan for prevention

services

• Can bill 99201- 99215, modifier 25, also G codes except

rectal

• Physicians and NPP’s

• Medlearn Matters Number: MM6223


Initial Annual Wellness (G0438)

ICN 905706

• History: HRA, Medical/FH; Risk/History Mood Disorder;

ask or observe hearing, ADL, fall risk, home safety;

Provider & Caregiver list

• Exam: BMI, BP, cognition

• Counsel: Written Screening Schedule 5-10 yrs, Risk

Factors (incl. mental health), Personalized Health Advice

(lifestyle, community resources, weight, physical activity,

falls, nutrition

• $173.70; One per lifetime


Subsequent Wellness Visit (G0438)

• Same as initial regarding required elements

• Just update

• Once per year; $117.71

• Can report with:

• E/M

• Labs, immunizations etc.

• Many other preventive services (see CCI edits)


It all adds up


Preventive Services Rules

• Many are primary care only

• Some have odd rules- see specific service

• Geriatrics At Your Finger Tips

• Time rules

• Cost sharing occasionally applies


CMS Issues: Improving

Payment Accuracy for

Primary Care, Care

Management, and Patient-

Centered Services

2017 Medicare Physician Fee Schedule

(MPFS) Final Rule

• Improve payment for care management services provided in

the care of beneficiaries with behavioral health conditions

(including services for substance use disorder treatment)

through new coding, including three codes used to describe

services furnished as part of the psychiatric collaborative care

management (CoCM) and one to address behavioral health

integration more broadly.

• Improve payment for cognition and functional assessment,

and care planning for beneficiaries with cognitive impairment.

• Adjust payment for routine visits furnished to beneficiaries

whose care requires additional resources due to their

mobility-related disabilities

2017 MPFS Final Rule

• Recognized for Medicare payment the additional CPT codes

within the chronic care management (CCM) family (for

complex CCM services) and adjust payment for the visit

during which CCM services are initiated (the initiating CCM

visit) to reflect resources associated with the assessment for,

and development of, a new care plan.

• Recognized for Medicare payment CPT codes for non-face-

to-face prolonged evaluation and management (E/M)

services by the physician (or other billing practitioner) that are

currently bundled, and increase payment rates for face-to-

face prolonged E/M services by the physician (or other billing

practitioner) based on existing RUC-recommended values.

Cognitive Impairment

Assessment and Care Plan

Services

Cognitive Impairment Assessment and

Care Plan Services

• In February 2016, the CPT Editorial Panel added a new code to describe an

evidenced-based cognitive service. This was one of several in response to

a CMS request to capture cognitive service codes not currently described

by E/M services.

• This service is provided when a comprehensive evaluation of a new or

existing patient exhibiting signs of cognitive impairment is required to

establish a diagnosis etiology and severity for the condition. The service

includes a thorough evaluation of medical and psychosocial factors

potentially contributing to increased morbidity.

• Typically, these patients are referred by a primary caregiver. There are 10

required elements for the service, and all 10 must be performed in order for

the code to be reported. This service includes two distinct activities,

assessment of the patient and establishment of care plan that is shared

with the patient and caregiver, along with education. It is important that all

elements are performed to be able to report this code. Other face-to-face

E/M codes cannot be reported on the same date as this service to prevent

any overlap with E/M codes.


Care Plan Services

In the CY2017 Final Rule, CMS will provide separate

payment for a service describing assessment and care

planning for patients with cognitive impairment using a new

G-code. This code will be temporary for only one year and

will presumably be replaced by the CPT code for CY2018.


Care Plan Services

G0505 Cognition and functional assessment using

standardized instruments with development of

recorded care plan for the patient with cognitive

impairment, history obtained from patient and/or

caregiver, by the physician or other qualified health

care professional in office or other outpatient setting

or home or domiciliary or rest home

Required Elements of G0505

• Cognition-focused evaluation including a pertinent history and

examination.

• Medical decision making of moderate or high complexity

(defined by the E/M guidelines).

• Functional assessment (for example, basic and instrumental

activities of daily living), including decision-making capacity.

• Use of standardized instruments to stage dementia.

• Medication reconciliation and review for high-risk

medications, if applicable.

Required Elements of G0505

• Evaluation for neuropsychiatric and behavioral symptoms, including

depression, including use of standardized instrument(s).

• Evaluation of safety (for example, home), including motor vehicle

operation, if applicable.

• Identification of caregiver(s), caregiver knowledge, caregiver needs,

social supports, and the willingness of caregiver to take on

caregiving tasks.

• Advance care planning and addressing palliative care needs, if

applicable and consistent with beneficiary preference.

• Creation of a care plan, including initial plans to address any

neuropsychiatric symptoms and referral to community resources as

needed (for example, adult day programs, support groups); care

plan shared with the patient and/or caregiver with initial education

and support.

Exclusions Finalized by CMS

Accordingly, CMS finalized that G0505 must be furnished by the

physician (or other appropriate billing practitioner) and could not

be billed on the same date of service as CPT codes:

• 90785 (Psytx complex interactive)

• 90791 (Psych diagnostic evaluation)

• 90792 (Psych diag eval w/med srvcs)

• 96103 (Psycho testing admin by comp)

• 96120 (Neuropsych tst admin w/comp)

• 96127 (Brief emotional/behav assmt)

• 99201-99215 (Office/outpatient visits new)

• 99324-99337 (Domicil/r-home visits new pat)


Exclusions Finalized by CMS (cont.)

Continuation from previous page of CPT codes that could not be billed on the

same date of service as G0505:

• 99341-99350 (Home visits new patient)

• 99366-99368 (Team conf w/pat by hc prof)

• 99497 (Advncd care plan 30 min)

• 99498 (Advncd care plan addl 30 min)

Because these codes all reflect face-to-face services provided by the physician

or other billing practitioner for related services that are separately payable.

In addition, CMS finalized to prohibit billing of G0505 with other care planning

services, such as care plan oversight services (99374), home health care and

hospice supervision (G0181, G0182), or our proposed add-on code for

comprehensive assessment and care planning by the billing practitioner for

patients requiring CCM services (G0506).


Separately Reportable

• CMS indicated that the services described by G0505

would not significantly overlap with the current medically

necessary

o CCM services (99487, 99489, 99490);

o TCM services (99495, 99496);

o or the behavioral health integration service codes

(G0502, G0503, G0504, G0507).

• CMS finalized that G0505 could be billed on the same

date of service or within the same service period as

codes 99487, 99489, 99490, 99495, 99496, G0502,

G0503, G0504, G0507.


CMS Guidelines & Service Period

• Only those practitioners eligible to report E/M

services should report.

• Outside of the specified elements, the regular

incident-to rules apply, consistent with other E/M

services

• No specific service period specified, subject to

contractor coverage policies.


National Rates 2017

Code Short Description 2017 NF MPFSNational Rate


G0505 Cog/func assessment outpt $238.30 $70.23

CMS Posted Typical Times

• Pre Service 15 min

• Intra-Service 50 min

• Immediate Post Service 20 min

• Total time = 85 minutes

Tips for Implementation

• CMS adopted CPT guidance that allows the prolonged time

(99358 and 99359) to be reported for time on a different day

than the companion E/M code, see CPT prefatory language for

CPT codes 99358 and 99359.

• This is allowed, for “extended non-F2F” review of records,

(similar to CCM initiating visit) CMS is likely to monitor this

combination.

• CMS may allow G0505 to be reported in the nursing home setting

• Do not report the new in 2017 HCPCS code G0506 with G0505

because a comprehensive care plan is part of G0505 and this

would be duplicative billing.

• If ALL of the required elements are NOT met, see E/M for billing.

Non-Face-To-Face Prolonged

Evaluation & Management

(E/M) Services

Non-Face-To-Face Prolonged E/M Services

In response to comments on the CY2016 Proposed Rule, for

2017 CMS established separate payment for non-face-to-face

prolonged E/M service codes that are currently considered to be

“bundled.” The codes are:

99358 Prolonged evaluation and management service

before and/or after direct patient care; first hour

99359 Prolonged evaluation and management service

before and/or after direct patient care; each

additional 30 minutes (List separately in addition

to code for prolonged service)


Non-Face-To-Face Prolonged E/M Services

• CMS intends that these codes be used to report extended non-face-to-face

time that is spent by the billing physician or other practitioner (not clinical

staff) that is not within the scope of practice of clinical staff, and that is not

adequately identified or valued under existing codes or the 2017 finalized

new codes.

• Based on CMS analysis of the comments, they do not believe there is

significant overlap between CPT codes 99358 and 99359 and the CCM

codes (CPT 99487, 99489, 99490) or the finalized behavioral health

integration (BHI) service codes (G0502, G0503, G0504, G0507).

• The work of the billing practitioner in the provision of non-complex CCM and

the BHI services is related to the direction of ongoing care management and

coordination activities of other individuals, compared to the work of 99358

and 99359, which is described as personally performed and directly related

to a face-to-face service.

• CMS adopts CPT 2017 for administrative simplification, i.e., no

reporting with complex chronic care or transitional care


National Rates 2017

Code Short Description/CMS Posted Typical Time(s)



99358 Prolong service w/o contactCMS Posted Typical Time

• Intra-Service 50 min• Total 50 min


99359 Prolong serv w/o contact addCMS Posted Typical Time

• Intra-Service 30 min• Total 30 min



• CMS adopted CPT guidance that allows the prolonged time

(99358 and 99359) to be reported for time on a different day

than the companion E/M code, see CPT prefatory language for

CPT codes 99358 and 99359.

• This is allowed, for “extended non-F2F” review of records,

(similar to CCM initiating visit) CMS is likely to monitor these

combination services and review documentation.

• Start and stop times not required documentation but extremely

helpful to defend services.

• Know the typical times for E/M and other services prior to billing,

ensure there is NO Overlap or Double Counting of Time.

Comprehensive Assessment

& Care Planning

Comprehensive Assessment & Care

Planning G0506

G0506 Comprehensive assessment of and care planning by

the physician or other qualified health care

professional for patients requiring chronic care

management services, including assessment during

the provision of a face-to-face service (billed

separately from monthly care management services)

(Add-on code, list separately in addition to primary

service).


Planning G0506

• CMS indicated that when the billing practitioner initiating CCM

personally performs extensive assessment and care planning

outside of the usual effort described by the billed E/M code (or

AWV or IPPE code), the practitioner could bill G0506 in addition to

the E/M code for the initiating visit (or in addition to the AWV or

IPPE), and in addition to the CCM CPT code 99490, if all

requirements to bill for CCM services are also met.

• Code G0506 would account specifically for additional work of the

billing practitioner in personally performing a face-to-face

assessment of a beneficiary requiring CCM services, and

personally performing CCM care planning (the care planning

could be face-to-face and/or non-face-to-face) that is not already

reflected in the initiating visit itself (nor in the monthly CCM service

code).



Planning G0506 (cont.)

• CMS indicated that G0506 might be particularly appropriate to

bill when the initiating visit is a less complex visit (such as a

level 2 or 3 E/M visit), although G0506 could be billed along

with higher level visits if the billing practitioner’s effort and

time exceeded the usual effort described by the initiating visit

code. It could also be appropriate to bill G0506 when the

initiating visit addresses problems unrelated to CCM, and the

billing practitioner does not consider the CCM-related work he

or she performs in determining what level of initiating visit to

bill.


Planning G0506 (cont.)

• CMS finalized that they will not permit the billing of G0506 more

than once by the billing practitioner for a given beneficiary.

• G0506 was proposed as an add-on code to the single initiating visit,

to help ensure the billing practitioner’s assessment and involvement

at the outset of CCM services.

• At this time there are no requirements for the billing practitioner to

“re-initiate” CCM services; therefore, CMS will not create an add-on

code for a CCM “re-initiation” service.

• CMS would have to define “re-initiation” and develop rules regarding

when subsequent E/M visits or AWVs are related to the

performance of CCM.

• CMS does not believe beneficiaries would understand why they are

incurring additional cost sharing for an add-on code to a “re-

initiation” visit that has not been required or defined by CMS.


Code Short DescriptionCMS Posted Typical Time(s)



+G0506 Comp asses care plan ccm svc5 / 16 / 7.5 Total Time 28.5 min




• CMS wrote that the practitioner could bill G0506 in addition to the

E/M code for the initiating visit (or in addition to the AWV or IPPE),

and in addition to the CCM CPT code 99490, if all requirements to

bill for CCM services are also met.

• Expect CMS to provide further clarification, this is confusing to

us.

• Bill either prolonged services or G0506, NOT both

• If you know the practice requirements for CCM, then you know the

practice requirements for G0506 as they are the same.

Behavioral Health Integration

(BHI) Care Management (other than Psychiatric Collaborative

Care Management)

BHI Care Management G0507

G0507 Care management services for behavioral health

conditions, 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:

• Initial assessment or follow-up monitoring, including the use of

applicable validated rating scales;

• Behavioral health care planning in relation to

behavioral/psychiatric health problems, including revision for

patients who are not progressing or whose status changes;

• Facilitating and coordinating treatment such as psychotherapy,

pharmacotherapy, counseling and/or psychiatric consultation; and

• Continuity of care with a designated member of the care team.

BHI Care Management G0507

• Established for Care Management of Behavioral Health Conditions

o In all settings

• Does not require structure of the evidence based model of Collaborative

Care Management

o Cannot report G0502, G0503, G0504 same month

• Does not require comprehensive care plan or comprehensive initiating

assessment of CCM

o Cannot report G0506

• Does require initiating E/M visit

• Does require “incident to” and general supervision

o But need not be embedded in a primary care practice

o Billing provider must have ongoing involvement with patient and care

manager

o Care manager must be available for face-to-face services

• Does not require all the practice attributes of 99490

o Uses same simplified consent







$47.73 $25.20



• The same provider may report both CCM 99490 and BHI

G0507, in the same calendar month, if each code is

independently eligible with NO overlap.

• CMS will be monitoring this code pair

• You may report G0507 for the patient that was in the

CoCM but did not meet the elements to bill any of the

G0502, G0503 or G0504 codes, but does meet the

G0507 elements.

• This may be an important element in estimating the

costs of CoCM to see if the practice can afford the

staff to provide those services.

Psychiatric Collaborative

Care Management Service(CoCM)

Psychiatric Collaborative Care

Management Services

In February 2016, the CPT Editorial Panel created three new codes to

describe a model for providing psychiatric care in the primary care

setting. This code set is one of several in response to a request from

CMS to facilitate appropriate valuation of the services furnished under

the Collaborative Care Model (CoCM).

CoCM is used to treat patients with common psychiatric conditions in

the primary care setting through the provision of a defined set of

services which operationalize the following core concepts:

1) Patient-Centered Team Care/Collaborative Care;

2) Population-Based Care;

3) Measurement-Based Treatment to Target; and

4) Evidence-Based Care.


Management Services

The new code set for Psychiatric Collaborative Care

Management captures a primary care physician working with a

behavioral health manager and consulting psychiatrist to manage

patient psychiatric care. At the April 2016 RUC meeting, the

specialty societies requested that this issue be deferred.


Management Services

• In the CY2016 Medicare Final Rule, CMS stated that they

believed that care and management for Medicare

beneficiaries with behavioral health conditions may include

extensive discussion, information sharing and planning

between a primary care physician and a specialist.

• In the CY2017 Medicare Final Rule, CMS is proposing

separate payment for services under the psychiatric CoCM

using three new G-codes. These codes will be temporary for

only one year and will presumable be replaced by the CPT

codes for CY2018.

Psychiatric Collaborative Care Management

Services CPT Codes (not yet valued)

G0502 Initial psychiatric collaborative care management, first

70 minutes in the first calendar month of behavioral health

care manager activities, in consultation with a psychiatric

consultant, and directed by the treating physician or other

qualified health care professional, with the following

required elements:

• Outreach to and engagement in treatment of a patient directed by

the treating physician or other qualified health care professional;

• Initial assessment of the patient, including administration of

validated rating scales, with the development of an individualized

treatment plan;

G0502, Initial Psychiatric Collaborative Care

Management (cont.)

• Review by the psychiatric consultant with modifications

of the plan if recommended;

• Entering patient in a registry and tracking patient follow-

up and progress using the registry, with appropriate

documentation, and participation in weekly caseload

consultation with the psychiatric consultant; and

• Provision of brief interventions using evidence-based

techniques such as behavioral activation, motivational

interviewing, and other focused treatment strategies.



G0503 Subsequent psychiatric collaborative care

management, first 60 minutes in a subsequent month

of behavioral health care manager activities, in

consultation with a psychiatric consultant, and directed

by the treating physician or other qualified health care

professional, with the following required elements:

• Tracking patient follow-up and progress using the registry, with

appropriate documentation;

• Participation in weekly caseload consultation with the psychiatric

consultant;

• Ongoing collaboration with and coordination of the patient's

mental health care with the treating physician or other qualified

health care professional and any other treating mental health

providers;

G0503, Subsequent Psychiatric Collaborative

Care Management (cont.)

• Additional review of progress and recommendations for

changes in treatment, as indicated, including medications,

based on recommendations provided by the psychiatric

consultant;

• Provision of brief interventions using evidence-based

techniques such as behavioral activation, motivational

interviewing, and other focused treatment strategies;

• Monitoring of patient outcomes using validated rating scales;

and relapse prevention planning with patients as they

achieve remission of symptoms and/or other treatment goals

and are prepared for discharge from active treatment.



G0504 Initial or subsequent psychiatric collaborative care

management, each additional 30 minutes in a calendar

month of behavioral health care manager activities, in

consultation with a psychiatric consultant, and directed by

the treating physician or other qualified health care

professional

(List separately in addition to code for primary procedure)

(Use G0504 in conjunction with G0502, G0503)





G0502 Init psych care manag, 70minIntra-Service 40 min

$142.84 $70.23

G0503 Subseq psych care man,60miIntra-Service 36 min

$126.33 $70.23

+G0504 Init/sub psych care add 30 mIntra-Service 18 min



$47.73 $25.20


CoCM and BHI Services


• The American Psychiatric Association (APA) has a grant

to train Psychiatrist in this model. Over the past year

many individuals have received training. If your site is

interested in contracting with a trained in the model

Psychiatrist, contact the APA staff Becky Yowell.

• Key to success is understanding how many patients will

enter this model or sharing resources with other CCM or

CoCM programs.

• Education for the BHCM and contracting with the

Psychiatrist.


• You may report G0507 for the patient that was in the

CoCM but did not meet the elements to bill any of the

G0502, G0503 or G0504 codes, but does meet the

G0507 elements.

• This may be an important element in estimating the

costs of CoCM to see if the practice can afford the

staff to provide the services.





G0502 Init psych care manag, 70minIntra-Service 40 min

$142.84 $70.23

G0503 Subseq psych care man,60miIntra-Service 36 min

$126.33 $70.23

+G0504 Init/sub psych care add 30 mIntra-Service 18 min


G0505 Cog/func assessment outpt15 / 50 / 20 Total Time 85 min

$238.30 $70.23

+G0506 Comp asses care plan ccm svc5 / 16 / 7.5 Total Time 28.5 min



$47.73 $25.20


Little Things?

Discharge Day: 99238 ($73.04) vs 99239 ($108.13)

F/U Visit: 99213 ($73.40) vs 99214 ($108.13)

Critical Care: 99233 ($104.91) vs 99291($225.93, office

$277.44)

Prolonged Services: 99354 ($100.97) and 99356

($98.10)

Electronic Medical Record Warning!

• Only you can select the

correct code

• “Replicate notes” are

gaining a lot of attention

• Documentation must

reflect actual services,

including review of

unchanged areas

• Copy and Paste has other

risk management issues

Contact Information

Peter Hollmann

[email protected]

mailto:[email protected]

Case One

A 68-year-old female is seen in the office for follow-uptreatment of diabetes and hypertension. Historyindicated that glucometer fasting readings run 100-130each morning. She has had no spells of weakness ordiaphoresis and continues to tolerate her metformin.She follows her diet and saw the ophthalmologist forher routine exam last month. She is tolerating herlisinopril and has a mild cough, which does not botherher. She has no CP or SOB. She notes chronic left kneepain, worse with activity. No trauma. It is swelling alittle. No fevers. Tylenol is ineffective.

On exam BP is 130/80, HR 68 Reg, weight is 142 stable,lungs clear, COR neg, ext no edema. Left kneeFROM, stable, small effusion, no calor or erythema.

The knee is tapped for 12cc of straw colored fluid and40 mg of Aristospan and one cc of 1% lido areinstilled. She is instructed to continue her currentmeds, to get a HgA1C and FBS. She is to reportincreased pain or redness in the knee or fever. She isto return in 3 months.

Questions Case 1

• What E/M code should be reported?

• Are there any other codes for which you can get paid?

• Is a modifier necessary?

• What would one code if the whole reason the patient was there was to get an intra-articular injection?

Answers Case 1

• What E/M code should be reported?

– D or PF history (ROS, PFSH), D or PF PE, Options/Data/Risk; 2/3; separation from injection

– A case can be made for 99213 or 99214.

• Are there any other codes for which you can get paid?

– 20610, J3303 (8 units)

• Is a modifier necessary?

– Modifier 25 on E/M

• What would one code if the whole reason the patient was there was to get an intra-articular injection?

– There is always some “E/M” in every procedure that is not separately reported.

Case Three

Mrs. Smith is a 79-year-old woman with a history of CADwho presents to the office with a history of shortnessof breath that is progressive. Last night she had chestheaviness and difficulty breathing. On exam she istachypneic, has rales ½ way up and increased pedaledema. Her pulse ox is 78%.

You call 911 and have the patient transported to thehospital. The ER is contacted, a med list and past EKGis faxed. She has been on ASA, a statin andmetoprolol. You document the visit.

After you finish with the other patients you go to thehospital.

You visit her in the hospital. A comprehensive historyand exam are performed. Data indicates CHF and asmall rise in troponin without EKG changes. By thetime you see her she has been treated with nitrates,diuretics and ASA. She is more comfortable. Her BP isin the low 90’s systolic. Her glucose is 480 without ananion gap. Her urine had 4-10 WBCs.

Questions Case 3

• What E/M is reported for the hospital admission?

• What E/M is reported for the office visit?

• What if you did the admission note the next day?

• What if your partner is on call for hospital admits and does the admit?

• What if your PA does the admit and then you come in later and complete the visit?

Answers Case 3

• What E/M is reported for the hospital admission?– 99223, see next question

• What E/M is reported for the office visit?– All same day services roll up into one service, but was this critical

care? Critical care can occur outside the ICU

• What if you did the admission note the next day?– Report by date of service, not date of admission. You could report

both outpatient and inpatient in this case.

• What if your partner is on call for hospital admits and does the admit?– Your partner is the same as you

• What if your PA does the admit and then you come in later and complete the visit?– Shared visit concept is applicable to inpatient care other than

consults.

Case Four

Mr. Atlas is a 68-year-old male who you last saw 4 yearsago for a checkup. He states he feels great, walks 5miles a day, lifts weights, but felt he should see youbecause he knew your daughter was in college andyou had tuition payments to make.

You review the interval history, which is negative. Youconfirm the past social and family histories. He doesnot smoke, only drinks if he goes out to dinner. Helimits it to 2 glasses of wine. His diet does notinclude sodium rich foods and he never adds salt. AROS checklist he filled out is negative and youconfirm this. He never got a Pneumovax and his onlymedication is an aspirin a day, a multivitamin, and400 IU of vitamin E. He has never had acolonoscopy or sig.

On exam, you note his BP to be 150-95. This isconfirmed in both arms and after rest. You do anddocument a complete PE which is all negativeincluding a negative rectal exam and stool OB. HisEKG is normal.

You ask him to come back in a month for a follow-upvisit. You ask him to stop by a couple of times tohave his BP checked before then. You order aHematocrit, fasting lipid panel and basic metabolicprofile. You give him the Pneumovax.

Questions Case 4

• What E/M code(s) are reported?

• Is this a new patient?

• What other codes are reported?

• Is this the IPPE exam? An Annual Wellness?

• Do I bill the patient or the payer?

Answers Case 4

• What E/M code(s) are reported?– 99202-25 for elevated BP, 99387 for Preventive Exam. Not HTN,

but is elevated BP. If comes back for BP check – 99211?

• Is this a new patient?– Yes

• What other codes are reported?– FOBT (CRC screen) not performed, stool OB not medically

necessary; G0102 (prostate) performed, but cannot report with E/M (CCI edit); pneumovax admin G0009 (or CPT if not Medicare) and supply 90732; 93000 (EKG).

• Is this the IPPE exam? AWV?– Not IPPE-not new to Medicare. Not AWV- services did not

conform

• Do I bill the patient or the payer?– Who is the payer? May get paid for BOTH 99202 and 99387 by

some, one E/M by others. Medicare: bill 99202 to CMS and deduct charge for 99202 from charge for 99387 and bill patient the difference. Will this be allowed with AWV benefits?

Case Five

You are a carrier medical director. You note that a localgeriatrician new to practice is billing 90% of his visitsat a level 5. While 30% are new patients, he isbilling most of his follow-up exams at 99215. Youask for five records of patients who received morethan one 99215.

You note he has an electronic medical record. HPI wasthorough. Each visit the doctor confirmsmedications, PFSH, and ROS. Each PE is extremelythorough and other than rectal/genital/breast examsis complete. One patient had moderate dementiawith severe behavioral problems. Phonedocumentation was extensive between visits. Twopatients had mild-moderate dementia and were fairlystable, seen every 3-4 months.

He documented good caregiver education. One patienthad compensated CHF as her primary reason forvisits every 3 months. Another patient had severeCOPD and anxiety. Even when seen monthly, she stillwas in the ER a couple of times. The recordsdocumented ER contact and retrieval of labs/x-rayshowever, she actually was not unstable and itappeared she needed constant reassurance. Thetreatment course was not changing.

The doctor indicates he uses an electronic record andthe computer suggested visit codes.

Question Case 5

• Is this physician coding correctly?

Answer Case 5

• No. All services must be medically necessary to count for each key element. An electronic carry forward of problem lists and drug lists is not taking a history. Computers really cannot assess medical decision making and relevant elements of history or exam.

Case 6

A 74 y/o male is day 2 after being admitted for CP.

You see him at 7AM and he is doing well on an

increased dose of beta blocker and nitrates. You

spent 17 minutes on the unit. Later that day he

develops more CP and ST changes are noted. He is

moved to the ICU, receives heparin and intravenous

NTG. You return to the hospital. You spend 48

minutes on the unit reviewing records, history/exam,

talking to the cardiologist and patient/family.

Questions Case 6

• How do I report two visits on one day?

Answer Case 6

• As a general rule only one E/M per day may be reported. Look at descriptor “per day” for inpatients.

• Two office visits can be reported, but will look like a duplicate claim. Hospital discharge and nursing facility admit same day may both be reported.

• Prolonged services may apply. (NB: NF is inpatient). Record your time. CMS rules all Prolonged Service is F2F only.

Case 7

A 83 y/o patient is treated by you at a hospital. You

discharge her to a nursing home where you intend

to follow her. This facility has a RNP who works

with all staff physicians and is available to see

patients on a daily basis. The RNP sees the patient

that day and does a comprehensive assessment.

You review the treatment plan with the RNP and

plan to personally assess the patient in 48 hrs.

When you come in you document a detailed history

and perform a problem focused exam given the

recent complete assessment in the hospital as well

as that of the RNP. Your plan is for rehab services

for her THR, continuation of anticoagulation

therapy,

order checking of PVRs for follow-up of a question of

retention, as well as continue her HTN treatment and

consider whether she requires an antidepressant for

some mood problems that you feel may be limiting

her recovery.

Questions Case 7

• How do I code when my service does not meet 3/3 elements?

• Is this a shared visit?

• Who gets to bill, me or the RNP or both?

• What if I saw the patient the day of admission?

Answers Case 7

• How do I code when my service does not meet 3/3 elements?– Unlisted codes are technically correct. Should you add

nonsense documentation or just code 99304 or use 2/3?

• Is this a shared visit?– There are no shared visits in the SNF/NF. Some may

argue that you can confirm the key components of the RNP work in your documentation in selecting the correct E/M.

• Who gets to bill, me or the RNP or both?– Same day only one could claim. An RNP may report

services prior to the admission assessment, if medically necessary.

• What if I saw the patient the day of admission?– See above

Teaching Rules

No allowance for med students

Bill for what you do, not what you write or rely upon

combined documentation supports the code

time based codes: your time only

If primary care center can bill lower codes (1-3)

Even if not present in room, prompt review

4:1, PGY over 6 months

Psych—must have visual.

Surg—must be present for key component of surgery

Modifiers

“-GC” resident involved

“-GE” ambulatory care ctr, if physician not F2F

Teaching Rules

– Both residents and teaching physicians may document physician services in the patient’s medical record. The documentation must be dated and contain a legible signature or identity and may be dictated and transcribed, typed, hand-written, or computer-generated.

– The attending physician who bills Medicare for evaluation and management (E/M) services in the teaching setting must, at a minimum, personally document his or her participation in the management of the patient and that he or she performed the service or was physically present during the critical or key portion(s) of the service performed by the resident (the resident’s certification that the attending physician was present is not sufficient).

– Students may also document services in the patient’s medical record. The teaching physician may refer only to a student’s E/M documentation that is related to a review of systems (ROS) and/or past, family, and/or social history (PFSH). If the student documents E/M services, the teaching physician must verify and repeat documentation of the physical examination and medical decision making activities of the service.

Teaching Rules

– For initial hospital care, emergency department visits, office visits for new patients, and office and hospital consultations, the teaching physician must enter a personal notation that demonstrates the appropriate level of service that the patient requires and documents his or her participation in the three key components. The three key components are history, examination, and medical decision making.

– If the teaching physician repeats key elements of the service components that the resident previously obtained and documented, his or her note may be brief, summarize comments that relate to the resident’s entry, and confirm or revise these key elements:

• Relevant history of present illness (HPI) and prior diagnostic tests• Major finding(s) of the physical examination • Assessment, clinical impression, or diagnosis and• Plan of care

Teaching Rules

– For subsequent hospital care and office visits for established patients, the teaching physician must enter a personal notation that highlights two of the three key components of these services. These components are history, physical examination, and medical decision making.

– For follow-up visits for established patients, the guidelines for initial hospital care, emergency department visits, office visits for new patients, and office and hospital consultations guidelines must also be followed.

Teaching Rules

– Medicare may grant a primary care exception within an approved Graduate Medical Education Program in which the teaching physician is paid for certain E/M services the resident performs when the teaching physician is not present. The primary care exception applies to the following lower and mid-level E/M services:

• New Patient - CPT® Codes 99201, 99202, and 99203 and• Established Patient - CPT Codes 99211, 99212, and 99213

– Effective January 1, 2005, the primary care exception also applies to the initial preventive physical examination, also known as the “Welcome to Medicare Physical” - Healthcare Common Procedure Coding System code G3044, the initial preventive physical examination, face-to-face visit, services limited to new beneficiary during the first six months of Medicare enrollment.

Acronym Glossary

Acronym Definition

BHI Behavioral health integration

BHCM Behavioral Health Care Manager

CCM Chronic care management

CoCM Collaborative care management

E/M Evaluation and management

MACRA Medicare Access and CHIP Reauthorization Act of 2015

MPFS Medicare physician fee schedule

OPPS Hospital - Outpatient Payment System

RVU Relative Value Units

TIP:TEAM CONFERENCES

• Team conference with patient present is E/M

• Can report as counseling and coordination of care

• Cautions – documentation, same tax ID

cpt coding 2017: basic principles and practice principles and practice peter a. hollmann md. peter...

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