Transcript slides for this presentation

Coding to Support Medical Home
Presented by
Janet Smith, RHIT, CPC
AHIMA Approved ICD-10 Trainer
Coding Educator
Tennessee Chapter of the
American Academy of Pediatrics
1
.
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
TOPICS:
•
•
•
•
•
•
•
Evaluation and Management
Prolonged Services
After-hours Codes
Care Plan Oversight
Complex Chronic Care Coordination
Transitional Care Management
Developmental/Behavioral Screening
Tennessee Chapter of the
American Academy of Pediatrics
3
New Patient
E/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
99382
99383
99384
99385
Age < 1 year
Ages 1 – 4 years
Ages 5 – 11 years
Ages 12 – 17 years
Ages 18 – 39 years
Tennessee Chapter of the
American Academy of Pediatrics
4
Established Patient
Reevaluation 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
99392
99393
99394
99395
Age < 1 year
Ages 1 – 4 years
Ages 5 – 11 years
Ages 12 – 17 years
Ages 18 – 39 years
Tennessee Chapter of the
American Academy of Pediatrics
5
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)
Tennessee Chapter of the
American Academy of Pediatrics
6
New Patients
99201
99202
99203
99204
99205
–
–
-
Straightforward, 10 minutes
Straightforward, 20 minutes
Low, 30 minutes
Moderate, 45 minutes
High, 60 minutes
Tennessee Chapter of the
American Academy of Pediatrics
7
Established Patients
99211
99212
99213
99214
99215
– Nurse visit, 5 minutes
- Straightforward, 10 minutes
– Low, 15 minutes
– Moderate, 25 minutes
– High, 40 minutes
Tennessee Chapter of the
American Academy of Pediatrics
8
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
Tennessee Chapter of the
American Academy of Pediatrics
9


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.
Tennessee Chapter of the
American Academy of Pediatrics
10
99214 = 25 minutes
99215 = 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.
Tennessee Chapter of the
American Academy of Pediatrics
11
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
Tennessee Chapter of the
American Academy of Pediatrics
12
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
Tennessee Chapter of the
American Academy of Pediatrics
13
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
Tennessee Chapter of the
American Academy of Pediatrics
14
99354 - reported for prolonged service of 30 to 74
minutes
99355 – reported for each additional 30 minutes
beyond the first hour
Tennessee Chapter of the
American Academy of Pediatrics
15
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
Tennessee Chapter of the
American Academy of Pediatrics
16
Code
99215
Fee
$139.77
99354
$95.87
Total = $235.64
For each additional 30 minutes:
Code
99355
Fee
$93.60
Tennessee Chapter of the
American Academy of Pediatrics
17
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
Tennessee Chapter of the
American Academy of Pediatrics
18
●
●
●
●
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
Tennessee Chapter of the
American Academy of Pediatrics
19
●
●
●
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
Tennessee Chapter of the
American Academy of Pediatrics
20
●
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
Tennessee Chapter of the
American Academy of Pediatrics
21
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
Tennessee Chapter of the
American Academy of Pediatrics
22
Code
Fee
99358
$105.09
For each additional 30 minutes:
Code
Fee
99359
$50.95
Tennessee Chapter of the
American Academy of Pediatrics
23
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 or
99358 X 1
75-104
(1 hr. 15 min. - 1 hr. 44 min.)
99354 X 1 and 99355 X 1 or
99358 X 1 and 99359 X1
105 or more
(1 hr. 45 min. or more)
99354 X 1 and 99355 X 2 or
99358 X 1 and 99359 X 2
or more for each additional 30
minutes
Tennessee Chapter of the
American Academy of Pediatrics
24
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
Tennessee Chapter of the
American Academy of Pediatrics
25

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
Tennessee Chapter of the
American Academy of Pediatrics
26
99051 - Services provided in the office during
regularly scheduled evening, weekend, or holiday
office hours, in addition to basic service
Tennessee Chapter of the
American Academy of Pediatrics
27

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
Tennessee Chapter of the
American Academy of Pediatrics
28
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”)
Tennessee Chapter of the
American Academy of Pediatrics
29
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.
Tennessee Chapter of the
American Academy of Pediatrics
30

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
Tennessee Chapter of the
American Academy of Pediatrics
31



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
Tennessee Chapter of the
American Academy of Pediatrics
32
99339 – Individual physician supervision of a patient
(patient not present) in home …15 -29 minutes
99340 - >30 minutes
Tennessee Chapter of the
American Academy of Pediatrics
33
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
Tennessee Chapter of the
American Academy of Pediatrics
34
Code
Fee
99340
$105.20
Care plan oversight 99340 billed for 12 months =
$1,262.40 per patient!
Tennessee Chapter of the
American Academy of Pediatrics
35
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
Tennessee Chapter of the
American Academy of Pediatrics
36
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
Tennessee Chapter of the
American Academy of Pediatrics
37
Code
Fee
99375
$101.59
Care plan oversight 99375 billed for 12 months =
$1,219.08 per patient!
Tennessee Chapter of the
American Academy of Pediatrics
38
Complex Chronic Care Coordination
and
Transitional Care Management
Codes for
Providers AND Clinical Staff Time
Tennessee Chapter of the
American Academy of Pediatrics
Patient-centered management and
support services provided by physicians,
other qualified health care professionals,
and clinical staff
Tennessee Chapter of the
American Academy of Pediatrics
40
●
●
●
●
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
Tennessee Chapter of the
American Academy of Pediatrics
●
●
●
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
Tennessee Chapter of the
American Academy of Pediatrics
42
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
Tennessee Chapter of the
American Academy of Pediatrics
43
●
●
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 selfmanagement, 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 plan
Tennessee Chapter of the
American Academy of Pediatrics
44
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 99487
Tennessee Chapter of the
American Academy of Pediatrics
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
Tennessee Chapter of the
American Academy of Pediatrics
Complex Care Coordination
99487 = $79.91
99488 = $179.27 (with face-to-face visit)
99489 = $40.12
Tennessee Chapter of the
American Academy of Pediatrics
●
●
●
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)
Tennessee Chapter of the
American Academy of Pediatrics
48
●
●
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
Tennessee Chapter of the
American Academy of Pediatrics
49
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
Tennessee Chapter of the
American Academy of Pediatrics
50
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
Tennessee Chapter of the
American Academy of Pediatrics
51
●
●
●
●
●
●
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 selfmanagement, 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
Tennessee Chapter of the
American Academy of Pediatrics
52
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.
Tennessee Chapter of the
American Academy of Pediatrics
53
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
Code 99495
Tennessee Chapter of the
American Academy of Pediatrics
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
Code 99496
Tennessee Chapter of the
American Academy of Pediatrics
Transitional Care Management (TCM)
99495 = $159.85
99496 = $225.35
Tennessee Chapter of the
American Academy of Pediatrics
56
Tennessee Chapter of the
American Academy of Pediatrics
•
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
Tennessee Chapter of the
American Academy of Pediatrics
58
•
•
Developmental Surveillance is recommended at ALL
ages as part of the history
Psychosocial/Behavioral Assessment is
recommended at ALL ages
Tennessee Chapter of the
American Academy of Pediatrics
59
Recommended Screenings:
•
•
•
•
Developmental Screening
9, 18 and 30 months
Autism Screening
18 and 24 months
Depression Screening (*New)
11-21 years
Alcohol and Drug use Assessment
11-21 years
Tennessee Chapter of the
American Academy of Pediatrics
60
96110 – Developmental screening, with interpretation and
report, per standardized instrument form
Examples of validated screening tools include but are not
limited to:
 M-CHAT
 PEDS
 Ages and Stages
 Pediatric Symptom Checklist
 Vanderbilt Scale for ADHD
 PHQ-2
Tennessee Chapter of the
American Academy of Pediatrics
61
•
•
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
Tennessee Chapter of the
American Academy of Pediatrics
62
•
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)
Tennessee Chapter of the
American Academy of Pediatrics
63
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:
EPDS
CRAFFT
Tennessee Chapter of the
American Academy of Pediatrics
64
•
•
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
Tennessee Chapter of the
American Academy of Pediatrics
65
•
•
•
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)
Tennessee Chapter of the
American Academy of Pediatrics
66
•
In order to report 96110 or 99420, the
medical record must include:
The screening tool
The tool must be completed and scored
Physician or provider signature
•
Use modifier –25 with E/M
The Tennessee Chapter of the
American Academy of Pediatrics
67
Code
Fee
96110
99420
$9.86
$10.54
Tennessee Chapter of the
American Academy of Pediatrics
68
Contact information:
Janet Smith, Coding Educator
Email: [email protected]
Phone: 615-447-3264
Please visit our website @ www.tnaap.org
Tennessee Chapter of the
American Academy of Pediatrics
69