Reimbursement for evaluation and management (EM) services is often the most challenging for primary care physicians and their billing staff. The most common EM codes are based on location, patient status, and level of service.
A good understanding of the opportunities, and a review of common errors found in audits, will help your practice obtain payment and peace of mind.
Prolonged Services
The 2016 Office of the Inspector General Work Plan includes a warning that the government plans to audit claims for CPT 99354-99356 for prolonged services with or without direct patient contact.
Prolonged services are for additional care provided to a beneficiary after an EM service has been performed. Physicians submit claims for prolonged services when they spend time in addition to the time spent with a beneficiary for a usual companion EM service. The necessity of prolonged services is considered to be unusual.
Apply the codes if: the time is documented; it is medically necessary; and the provider was attending the patient the entire time (e.g. for chest pain or respiratory distress.) The codes should not be used if the provider was in and out seeing other patients during the time interval. Direct (face-to-face) patient contact is required. Only count the time spent face-to-face, even if the time is not continuous.
Prolonged service CPT codes 99354 and 99355 were revised in 2016 to report EM or psychotherapy services and can now be reported with 90837 (psychotherapy) as well as 99201-99215 (office visits), 99241-99245 (outpatient consultations), 99324-99337 (residential/assisted living) and 99341-99350 (home services)
The 2016 CPT included the new code 99415. It covers prolonged clinical staff service (service beyond the typical service time) during an EM visit in the office or outpatient setting, direct patient contact with physician supervision; first hour (list separately in addition to code for outpatient EM service). Use code 99416 for reporting each additional 30 minutes. The prolonged services codes cannot be reported for more than two patients at the same time.
Common errors: Audits of claims for prolonged services frequently show that this “time-based” code is not supported by documentation of time. Prolonged service code(s) may be added to a base EM code only by the rendering provider.
Prolonged service codes cannot be used to represent cumulative episodes of care by multiple, same-specialty providers within a group. While there is no required time format, many carriers recommend clock time (for example, 11 a.m. to 11:45 a.m.) but will also accept time documented as “45 minutes was spent.” The note should support how the time was spent.
Advanced care planning
Many physicians spend time with patients and their families discussing end-of-life issues. The Annual Wellness Visit (AWV) is one opportunity to have this discussion.
Effective January 1, 2016, the Centers for Medicare & Medicaid Services (CMS) has said that it would allow payment when furnished as an optional element of the AWV and waive the deductible and coinsurance. However, these codes are not limited to primary care providers, and can be furnished in settings beyond the AWV. Neurologists and oncologists, for example, also have these discussions and can bill for advance care planning (ACP).
ACP can occur at any time. When ACP occurs during another visit, such as EM, Chronic Care Management (CCM) or Transitional Care Management (TCM), there will be cost sharing, in the form of copays and deductibles, similar to other physicians’ services.
CPT 99497 for ACP includes the explanation and discussion of advance directives such as standard forms, with completion of such forms when performed by the physician or other qualified healthcare professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate. CPT 99498 can be used to report each additional 30 minutes.
These codes are not bundled with Medicare’s covered preventive services such as Initial Preventive Physical Exam G0402 or AWV G0438 (initial) or G0439 (subsequent). The CPT code(s) for ACP should be billed using modifier -33, and no Part B coinsurance or deductible (consistent with the AWV) will apply.
Common errors: Missing the opportunity to report this service is the biggest mistake at this early stage. Start using the code, but don’t forget to document each element of the service.
The ACP codes (99497 and 99498) cannot be reported with critical care codes in any category and they exclude treatment and management plans for an active problem.
Transitional Care management
The billing date requirement for use of the TCM codes has created workflow problems for providers and their billing staff.
Since January, CMS has offered new date of service options for TCM reporting. CMS now allows submission of the claim on the date of the face-to-face visit, consistent with the current policy governing the reporting of global surgery and other bundles of services under the Medicare Physician Fee Schedule.
Common errors: Practices must document the contact with the patient within two business days. Electronic health record (EHR) systems that have a telephone log make it easy to comply with this requirement.
Develop a workflow that can track your patients in the hospital, their dates of discharge and the dates of contact with them. Calls to initiate or restart community services, medication reconciliation, and instructions also should be documented.
Annual wellness visit
Medicare established two codes (GO438 and GO439) for billing and reimbursement of an AWV in 2011. This service continues to be underused and underdocumented.
A common mistake is to use the EHR template for an “annual physical.” The components are quite different. Using a checklist, ask your EHR clinical documentation support specialist to create a template that will capture all the required elements. Also, be sure to scan or include a copy of the patient’s Health Risk Assessment form.
Depression screening can be performed in writing by the patient or verbally by the provider. The responses should be documented in the body of the note.
Another screening element is for cognitive impairment. Use a tool such as a mini-mental status exam (MMSE) or the Saint Louis University Mental Status (SLUMS) Dementia exam and record the results.
Don’t forget to list providers involved in the care of the patient. This can be done by adding the names of the specialists managing specific problems on the patient’s problem list.
The timing of the AWV codes is important to track. Patients enrolled in Medicare for less than a year should receive their Initial Preventive Physical Exam (IPPE) followed by their Initial AWV 11 calendar months after the IPPE. Both the IPPE and initial AWV (G0438) are “once in a lifetime” benefits. The beneficiary becomes eligible for a subsequent AWV (G0439) after 11 full months have passed since their last AWV.
Common errors: Many providers avoid using the AWV codes due to a lack of understanding of the timing or documentation, and report a high level EM service once a year when the patient comes in for an “annual” and they assess multiple chronic health problems.
Auditors will spot this quickly when the appointment type is listed as “annual physical,’ the chief complaint is documented as a “physical,” and most importantly, when there is no History of Present Illness (HPI) to support the extent of the comprehensive physical exam, and no assessment and change in the plan of care.
Counseling, risk factor reduction and behavior change intervention
CPT codes 99401-99429 provide an opportunity to bill for preventive medicine (outside of an annual physical) behavior change
intervention in an individual or a group
setting.
There are four codes in the range of 99401 to 99404 based on 15-minute intervals for preventive medicine counseling and/or risk factor reduction interventions. Issues such as a healthy diet, exercise and drug abuse or contraception and healthy lifestyle may be reported.
Counseling focused on smoking can be reported in addition to EM services on the same date:
99406: Smoking and tobacco use cessation counseling visit; intermediate, greater than
3 minutes up to 10 minutes
99407: Smoking and tobacco use cessation counseling visit; intensive, greater than
10 minutes
Counseling for alcohol and/or substance abuse (other than tobacco) are reported with:
99408: Alcohol- and/or substance-
(other than tobacco) abuse structured screening (e.g., AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes
99409: Alcohol- and/or substance- (other than tobacco) abuse structured screening (e.g., AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes
Code 99078 should be reported for patients who have existing symptoms or illness: physician or other qualified healthcare professional qualified by education, training, licensure/regulation (when applicable) educational services rendered to patients in a group setting (e.g., prenatal, obesity or diabetic instructions).
Codes 99411 and 99412 can be used to report preventive medicine counseling and/or risk factor reduction intervention(s) provided to individuals in a group setting (separate procedure); based on time: 30 minutes and 60 minutes, respectively.
Common errors: Check insurance carriers for their reimbursement policies based on coverage guidelines, and be sure to document the time spent, as well as the discussion.
Time-based codes require careful documentation of time spent, with clock time (e.g. 11 a.m. to 11:30 a.m.) and a summary of the discussion. Medicare does not cover this range of codes, but does accept alternative “G” codes for smoking cessation (G0436-G0437.)
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Originally Published On: Medical Economics
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