New CPT Codes Effective For Physicians in 2017
Please be sure to call Cape Medical Billing to let us know which new codes you will use so we can add them to your fee schedule. That will avoid a delay until the code(s) is added. If you have a fee preference, let us know that also.
As always, some codes are not covered by all insurers. The 5 codes below are ALL covered by Medicare effective 1/1/17.
We hope the Summary below is helpful to you. It includes the detailed descriptions for each CPT code. See below.
New payments by Medicare for Collaborative Care and Care Management Services – All Clinical Providers
CMS finalized a number of payment changes designed to increase coverage for primary care, care management and other cognitive services. The agency adopted CPT codes 99358 and 99359 to pay separately for non-face-to-face prolonged E/M services before or after direct patient care, which are currently considered to be bundled under the PFS, beginning Jan. 1, 2017.
99358 Prolonged evaluation and management service before and/or after direct patient care; first hour
Report this service if the provider spends time in either preparation or evaluation of the outcome of treatment before or after the face–to–face encounter with a patient.
Clinical Responsibility
For first–hour code 99358, the provider should spend a minimum of 30 minutes on the patient’s indirect care. For this service, the provider puts extra effort and time into the treatment of the patient. For example, the provider evaluates the patient’s previous records in cases where the patient opted to change his provider and the new provider performs extra work to understand and plan the treatment of the patient. The provider can also invest extra time to review the reports and progress after the patient has undergone treatment.
Terminology
Prolonged evaluation and management service: An evaluation and management service that takes more than average or stipulated time to perform.
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)
Report this service if the provider spends time in either preparation or evaluation of the outcome of treatment before or after the face–to–face encounter with a patient. This code represents each additional 30 minutes after the first hour of time.
Clinical Responsibility
For additional 30–minute code +99359, the provider should spend a minimum of 15 additional minutes after the first hour on the patient’s indirect care. For this service, the provider puts extra effort and time into the treatment of the patient. For example, the provider evaluates the patient’s previous records in cases where the patient opted to change his provider and the new provider performs extra work to understand and plan the treatment of the patient. The provider can also invest extra time to review the reports and progress after the patient has undergone treatment.
Terminology
Prolonged evaluation and management service: An evaluation and management service that takes more than average or stipulated time to perform.
Because +99359 is an add–on code, payers will not reimburse you unless you report it with an appropriate code for the initial hour of additional time: 99358.
· This is only for work performed by a physician or qualified health professional (e.g., PA, NP, etc.) (does not include non-clinical staff time).
· The codes may be used on the same day as an E&M service or a different day.
· May not be reported during a TCM 30 day period OR during the month a CCM is billed.
· May be reported with G0505, cognitive assessment, but don not double count the time.
· May not be billed with G0506 (see below).
· Be sure to also document your start and stop times in case you are audited.
· These are subject to deductible and co-insurance the same as most other Medicare codes so you may want to notify patients in advance of billing those charges to Medicare.
CMS also finalized creation of code G0505 for separate payment for assessing and creating acare plan for beneficiaries with a cognitive impairment (e.g., dementia).
Improvements to chronic care management (CCM) payment and billing requirements – PCP’s
In response to MGMA advocacy efforts, CMS mitigated the extensive and onerous requirements to billing CCM services. Specifically, CMS finalized the following improvements:
• Limiting the face-to-face initiating visit requirement to CCM patients who are new or who have not been seen within the past year, rather than all beneficiaries receiving CCM services.
• Creating a G-code (G0506) as an add-on payment for initiating visits that involve care planning beyond the scope of the initiating visit.
G0506: Comprehensive assessment of and care planning by the physician or other qualified healthcare professional for patients requiring chronic care management services, including assessment during the provision of a face to face service (billed separately for monthly care management services) (add-on code, list separately in addition to the primary service – that means in addition to the E&M code).
• Removing the requirement that practitioners furnishing CCM after hours must have access to the electronic care plan.
• Permitting billing practitioners to share electronic care plan information with practitioners furnishing after-hours urgent care on a timely basis rather than mandating
24/7 access to the electronic care plan. CMS will also allow transmission of the care plan by fax.
• Modifying the requirement to share clinical summaries during transitions of care to require the billing practitioner to share “continuity of care” documents.
• Providing more flexibility to practices to determine the best format for sharing a care plan with a patient or a patient’s caregiver.
• Allowing documentation of the beneficiary’s consent in the medical record rather than requiring a separate written agreement.
• Eliminating the requirement to use certified EHR technology to document communication with home- and community-based providers regarding the beneficiary’s psychosocial needs and functional deficits.
CMS also adopted CPT codes 99487 and 99489 to cover more complex and time-intensive CCM services. These services have the same billing requirements as the existing CCM code, and therefore can only be billed once per calendar month by one practitioner who provides care management for the beneficiary in that month.
99487: Complex chronic care management services, with the following required elements:
· multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient,
· chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline,
· establishment or substantial revision of a comprehensive care plan,
· moderate or high complexity medical decision making;
· 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.
Notes: (Complex chronic care management services of less than 60 minutes’ duration, in a calendar month, are not reported separately)
99489: Complex chronic care management services, with the following required elements:
· multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient,
· chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline,
· establishment or substantial revision of a comprehensive care plan,
· moderate or high complexity medical decision making;
each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure)
Notes:
(Report 99489 in conjunction with 99487)
(Do not report 99489 for care management services of less than 30 minutes additional to the first 60 minutes of complex chronic care management services during a calendar month)