tennessee chapter of the american academy of pediatrics 1 coding to support medical home presented...

Tennessee Chapter of the American Academy of Pediatrics

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Coding to Support Medical Home

Presented byJanet Smith, RHIT, CPC

AHIMA Approved ICD-10 TrainerCoding Educator

The Tennessee Chapter of the American Academy of Pediatrics (TNAAP) is an independent organization. The information contained herein is intended for reference purposes only, and any other use (including, without limitation, copying, transmission or dissemination) is strictly prohibited. TNAAP attempts to provide accurate information; however, neither the publisher, editors, board members, contributors nor consultants warrant, guarantee or will be responsible for the accuracy, completeness, appropriateness or acceptability of any information contained herein. The materials and information provided by TNAAP do not substitute for the professional judgment of a medical practitioner or provider.

The American Medical Association (AMA) claims copyright (2013) in the CPT codes, nomenclature and other data. All use of the AMA’s information shall be in accordance with the rights granted, if any, directly to a medical practitioner or provider by the AMA.

Tennessee Chapter of the American Academy of Pediatrics 2

Disclaimer

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TOPICS: • Evaluation and Management• Prolonged Services • After-hours Codes• Care Plan Oversight• Complex Chronic Care Coordination• Transitional Care Management• Developmental/Behavioral Screening


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New PatientE/M of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient

99381 Age < 1 year99382 Ages 1 – 4 years99383 Ages 5 – 11 years99384 Ages 12 – 17 years99385 Ages 18 – 39 years


Preventive/EPSDT visits

Established PatientReevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient

99391 Age < 1 year99392 Ages 1 – 4 years99393 Ages 5 – 11 years99394 Ages 12 – 17 years99395 Ages 18 – 39 years


Preventive/EPSDT visits

Separately Reportable Services with EPSDT/Preventive:

• Evaluation and Management (preventive)• Hearing/Vision Screens• Vaccine Administration• Lab procedures such as Hemoglobin and Lead• Use of Developmental/Behavioral Screening Tools• Health Risk Assessments• Significant and Separately Identifiable E/M services (eg,

sick)• Unrelated Procedures (eg, wart removal)


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Reimbursement for EPSDT

New Patients

99201 – Straightforward, 10 minutes99202 – Straightforward, 20 minutes99203 - Low, 30 minutes99204 - Moderate, 45 minutes99205 - High, 60 minutes


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Office Visits

Established Patients

99211 – Nurse visit, 5 minutes99212 - Straightforward, 10 minutes99213 – Low, 15 minutes99214 – Moderate, 25 minutes99215 – High, 40 minutes


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Office Visits

If the provider is spending at least 25 minutes with the patient and over 50% of that time is counseling and coordinating care, 99214 can be reported.

Provider must document time and describe the counseling/care coordination provided


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Time is on Your Side!

Rules on Time Time is face-to-face time with the patient for

office and other outpatient visits and as unit/floor time for hospital and other inpatient visits

A unit of time is attained when the mid-point is passed◦ For example, an hour is attained when 31 minutes have elapsed

(more than midway between 0 and 60 minutes). A second hour is attained when a total of 91 minutes have elapsed.

When codes are ranked by typical times and the actual time is between two typical times, the code with the time closest to the actual time is used.


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Time Example

99214 = 25 minutes99215 = 40 minutes

If the provider spends 35 minutes with the patient and over 50% of the time is spent in counseling/coordination of care, the provider can report 99215 because the time falls closer to 40 minutes than 25 minutes.


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E/M Typical Times

Code Typical Time Minimum Time

99201 10 min N/A

99202 20 min 16 min

99203 30 min 26 min

99204 45 min 38 min

99205 60 min 53 min

99211 5 min N/A

99212 10 min 8 min

99213 15 min 13 min

99214 25 min 21 min

99215 40 min 33 min


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Time Makes a Difference!

Code MC 2013 Fee Difference(from previous level)

99212 $42.52

99213 $70.63 $28.11

99214 $104.02 $33.39

99215 $139.77 $35.75


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99354 and 99355 - Prolonged Services With Direct Face-to-Face Contact

Time spent must be face-to-face with the patient/family

Reported with any level E/M service when the primary E/M code has an assigned time

Time does not have to be continuous but is reported for services provided on the same calendar day


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Additional Time? Additional Codes!

99354 - reported for prolonged service of 30 to 74 minutes

99355 – reported for each additional 30 minutes beyond the first hour


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Prolonged Service Face to Face

A 9-month-old previously healthy child is seen in follow-up for failure to gain weight and increasing irritability with recurrent bouts of constipation. Because of a family history of gluten intolerance, the physician wants to refer the child to a pediatric gastroenterologist. The parents are resistant to the referral. A total of 40 minutes was spent in providing the face-to-face E/M service and 30 minutes was spent in counseling the parents.

Office visit – 99215 (40 minutes average time)Prolonged service 30 minutes - 99354


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Example

Code Fee99215 $139.77

99354 $95.87

Total = $235.64

For each additional 30 minutes:

Code Fee99355 $93.60


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Reimbursement

99358 and 99359

are used when a physician provides prolonged service not involving direct (face-to-face) care that is beyond the usual non-face-to-face component of physician service time


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Prolonged Service Non Face to Face

● Reported with another physician service, including E/M service at any level

● May be reported on a different date than the primary service to which it is related

● Must relate to a service or patient where direct (face-to-face) patient care has occurred or will occur and relate to ongoing patient management

● A typical time for the primary service need not be established


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● 99358 and 99359 are used to report the total duration of non face-to-face time providing prolonged service, even if the time is not continuous

● 99358 should only be used once per date for the first hour of prolonged service

● 99359 is used to report each additional 30 minutes beyond the first hour regardless of the place of service


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● Do not report 99358 and 99359 for time spent in:

• Medical team conference• Care plan oversight services • Or other non-face-to-face codes that have

more specific codes and no upper time limit


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Prolonged Service

The provider spends 40 minutes in his office reviewing extensive medical records that are received the day after a patient is admitted to the hospital.

Report 99358


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Example

Code Fee

99358 $105.09

For each additional 30 minutes:

Code Fee

99359 $50.95


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Reimbursement

Total Duration of Prolonged Services

Code(s)

less than 30 minutes Not reported separately

30-74 minutes (1/2 hr. - 1 hr. 14 min.)

99354 X 1 or99358 X 1

75-104(1 hr. 15 min. - 1 hr. 44 min.)

99354 X 1 and 99355 X 1 or99358 X 1 and 99359 X1

105 or more (1 hr. 45 min. or more)

99354 X 1 and 99355 X 2 or99358 X 1 and 99359 X 2or more for each additional 30 minutes


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Prolonged Services Outpatient

99050 – Provided in office at times other than regularly scheduled office hours, or days when office is normally closed (eg, holidays, Saturday, or Sunday) in addition to basic service


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After Hours

Regular office hours are M-F 8:00 am - 5:00 pm

Patient is seen at 6:00 pm

Report E/M and 99050: 99213 99050


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Example

99051 - Services provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service


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After Hours

Regular office hours are 8:00 to 12:00 on Saturday

Patient is seen at 9:00 on Saturday

Report E/M service and 99051 ie: 99214 99051


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Example

99050 and 99051 do not have established RVUs

Typical Reimbursement range for 99050:$15.00 - $30.00

Most payers do not reimburse for 99051

(**You may be able to negotiate with payers to use 99050 for “posted after-hours care”)


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Reimbursement

Recurrent physician supervision of a complex patient who requires multidisciplinary care and ongoing physician involvement. These services are not face to face and reflect the complexity of time required to supervise the care of the patient.


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Care Plan Oversight

Regular physician development and/or revision of care plans

Review of subsequent reports of the patient’s status

Review of related laboratory or other diagnostic studies

Communication (including telephone calls) for purposes of assessment or care decisions with health care professionals, family members…involved in the patient’s care

Team conferences


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Care Plan Oversight

Reported based on the amount of time spent by the physician within a calendar month beginning with the first day of the month and ending with the last day of the month

Reported based on the patient’s location (eg, home, hospice) and the total time spent by the physician with in the calendar month. Less than 15 minutes cumulative time within a calendar month cannot be reported

Reported separately from other E/M services


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Care Plan Oversight

99339 – Individual physician supervision of a patient (patient not present) in home …15 -29 minutes

99340 - >30 minutes


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Care Plan Oversight

4-year old child with cerebral palsy at home. Provider documents time spent on telephone calls with mother regarding team conference, makes revisions to plan of care, refers the child to speech therapy, and discusses with her the assessment and plan. A total of 43 minutes was spent in the provision of care plan oversight.

Report 99340


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Example

Code Fee

99340 $105.20

Care plan oversight 99340 billed for 12 months = $1,262.40 per patient!


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Reimbursement

99374 – Physician supervision of a patient under care of a home health agency (patient not present) in home, domiciliary, or equivalent environment….15-29 minutes

99375 - >30 minutes


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Care Plan Oversight

4-year old child with cerebral palsy under care of home health agency. Provider documents time spent on telephone calls with mother regarding team conference, makes revisions to plan of care, refers the child to speech therapy, and discusses with her the assessment and plan. A total of 43 minutes was spent in the provision of care plan oversight.

Report 99375


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Example

Code Fee

99375 $101.59

Care plan oversight 99375 billed for 12 months = $1,219.08 per patient!


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Reimbursement

Complex Chronic Care Coordination

and Transitional Care Management

Codes for Providers AND Clinical Staff Time


Complex Chronic Care Coordination Services

Patient-centered management and support services provided by physicians, other qualified health care professionals, and clinical staff


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● Patients in home or in rest home, or assisted living facility

● Clinical staff implementing a care plan directed by the physician

● Address the coordination of care by multiple disciplines and community service agencies

● The reporting individual provides or oversees the management and/or coordination or services, as needed for all medical conditions, psychosocial needs, and activities of daily living




● These services include moderate- or high-complexity medical decision-making within a calendar month

● A plan of care should be documented and shared with the patient and/or caregiver

● The face-to-face and non-face-to-face time spent by the clinical staff in communicating with the patient and/or family, caregivers, other professionals and agencies; revising, documenting and implementing the care plan; or teaching self management is used in determining the clinical staff time for the month


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Complex Chronic Care Coordination Services 99487 – First hour of clinical staff time directed by a physician or other qualified health care professional with no face-to-face visit, per calendar month

99488 – First hour of clinical staff time directed by a physician or other qualified health care professional with one face-to-face visit, per calendar month

+99489 – each additional 30 minutes (list separately in addition to the code for primary procedure)

Additional E/M services beyond the 1st visit may be reported separately


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● communication (with patient, family members, guardian or caretaker, surrogate decision makers, and/or other professional) regarding aspects of care

● communication with home health agencies and other community services collection of health outcomes data and registry documentation

● patient and/or family/caretaker education to support self-management, independent living, and activities of daily living

● assessment and support for treatment regimen adherence and medication management

● identification of available community and health resources;

● facilitating access to care and services needed by the patient and/or family

● development and maintenance of a comprehensive care planTennessee Chapter of the

American Academy of Pediatrics44

A 6-year old has spastic quadriplegia, gastrostomy, gastroesophageal reflux with recurrent bouts of aspiration pneumonia and reactive airway disease, chronic seizure disorder, failure to thrive and severe neurodevelopmental delay.

He receives home occupational, physical, and speech therapy services

A total of 40 minutes was spent care coordination for the month

Code 99487Tennessee Chapter of the

American Academy of Pediatrics

Example

A 12-year old has severe atopic disease and recurrent asthma, which has led to multiple ED visits, hospital admissions, lost school days, and behavioral adjustment reactions.

The child has one office visit and 40 minutes was spent in care coordination during the calendar month

Code 99488


Example

Complex Care Coordination

99487 = $79.91

99488 = $179.27 (with face-to-face visit)

99489 = $40.12


Reimbursement

Transitional Care Management Services (TCM)

● For new or established patients whose medical and/or psychological problems require moderate or high complexity medical decision-making

● During transitions in care from an inpatient hospital setting (including observation status in a hospital, or skilled nursing facility/nursing facility)

● To the patient’s community setting (home, domiciliary, rest home, or assisted living)


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Transitional Care Management Services(TCM)

● TCM is comprised of one face-to-face visit within the specified time frames, in combination with non-face-to-face time that may be performed by the physician or other qualified health care professional and/or licensed clinical staff under his or her direction

● Additional E/M services beyond the 1st visit may be reported separately


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Requirements:

• Within 2 business days of discharge, an interactive contact with the patient or caregiver must take place. This contact can be face-to-face or by telephone or electronic means

• A face-to-face visit must take place within 7-14 calendar days following discharge depending on the complexity of the patient and code reported.

• Medication reconciliation and management must take place no later than the date of the first face-to-face visit following discharge


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99495

• Communication with the patient and/or caregiver within 2 business days of discharge

• Medical decision making of at least moderate complexity

• Face-to-face visit, with 14 calendar days of discharge

99496

• Communication with the patient and/or caregiver within 2 business days

• Medical decision making of high complexity • Face-to-face visit, within 7 calendar days of discharge


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● communication (with patient, family members, guardian or caretaker, surrogate decision makers, and/or other professionals) regarding aspects of care

● communication with home health agencies and other community services utilized by the patient

● patient and/or family/caretaker education to support self-management, independent living, and activities of daily living

● assessment and support for treatment regimen adherence and medication management

● identification of available community and health resources

● facilitating access to care and services needed by the patient and/or family


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Transitional Care Management Services (TCM)Non-face-to-face services provided by the physician or other qualified health care professional may include:

● obtaining and reviewing the discharge information; ● reviewing diagnostic tests and treatments;● interaction with other qualified health care professionals

who will assume or reassume care of the patient…;● education of patient, family, guardian, and/or caregiver;● establishment or reestablishment of referrals and arranging

for needed community services● assistance in scheduling follow-up with community

providers and services.


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A 6-year old who is neurologically impaired and developmentally delayed and has chronic seizure disorder is discharged from the hospital after an admission for breakthrough seizures.

Two days after discharge the physician speaks with the mother. The clinical staff assesses adherence with treatment plan and educates the parents on management of the child. The child is seen for an office visit 10 days after discharge. Medical decision making is moderate



Example

A 6-month old born at 25 weeks’ gestation with a chronic lung disease on home oxygen, diuretics, bronchodilators, and high-caloric formula is discharged from the hospital after admission for respiratory failure.

The physician speaks with the mother the day after discharge. Clinical staff assesses adherence to the treatment plan and educates parents on management of the child. The child is seen in follow up in 5 days. Medical decision making is high



Example

Reimbursement

Transitional Care Management (TCM)

99495 = $159.85

99496 = $225.35


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Developmental and Behavioral Screening

• Specific Age Recommendations from the AAP to allow for:

Earlier detection Earlier treatment Better outcomes for children with

developmental delays

• Most payers recognize the value and will reimburse for this service


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Benefits of Developmental/Behavioral Screening

Developmental/Behavioral Assessments

• Developmental Surveillance is recommended at ALL ages as part of the history

• Psychosocial/Behavioral Assessment is recommended at ALL ages


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Developmental/Behavioral ScreeningRecommended Screenings:

• Developmental Screening9, 18 and 30 months

• Autism Screening18 and 24 months

• Depression Screening (*New) 11-21 years

• Alcohol and Drug use Assessment11-21 years


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Developmental/Behavioral Screening Coding

96110 – Developmental screening, with interpretation and report, per standardized instrument form

Examples of validated screening tools include but are not limited to:

M-CHATPEDSAges and StagesPediatric Symptom ChecklistVanderbilt Scale for ADHDPHQ-2


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• 96110 is normally utilized in conjunction with an EPSDT visit

• If this screening is done in conjunction with preventive service, report modifier -25 with the preventive service code


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• If more than one screening tool is used, i.e., PEDS and MCHAT:

Use modifier -59 to indicate distinct procedure

• If the same tool is used more than once, i.e., ADHD tool for teacher and parent:

Use modifier -76 to indicate same procedure, same day

**(Some payers will only accept the modifier 59 with multiple screens or may require that you report multiple screens in units, ie, 96110 X 2)


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Health Risk Assessment Code

99420 – Administration and interpretation of health risk assessment instrument (eg, health hazard appraisal)

Must be scored and results documented!

Examples of health risk assessments include but are not limited to:

EPDSCRAFFT


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Edinburgh Postnatal Depression Scale (EPDS)

• The AAP now recommends reporting CPT code 99420 for the Edinburgh Postnatal Depression Scale (EPDS), recognizing the Edinburgh scale as a measure for risk in the infant’s environment

• The EPDS is to be appropriately billed at the infant’s visit under the mother’s ID number until the infant receives their on ID number


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Alcohol and Drug Use Assessment

• The CRAFFT is recommended for screening for Alcohol and Drug Use Assessment

• The CRAFFT may be reported with 99420

• If the CRAFFT is positive and a brief intervention service is also performed, report 99408 instead

(Do not report 99420 in addition to 99408)


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• In order to report 96110 or 99420, the medical record must include:

The screening tool The tool must be completed and scoredPhysician or provider signature

• Use modifier –25 with E/M

The Tennessee Chapter of the American Academy of Pediatrics 67

REMEMBER

Code Fee

96110 $9.8699420 $10.54


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Reimbursement

Contact information:

Janet Smith, Coding Educator

Email: [email protected]: 615-447-3264

Please visit our website @ www.tnaap.org


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QUESTIONS?

mailto:[email protected]

http://www.tnaap.org/

tennessee chapter of the american academy of pediatrics 1 coding to support medical home presented...

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