A new year means new codes and new revenue opportunities for medical practices—but also new challenges to ensure the codes are used correctly.
Below is a brief summary of new current procedural terminology (CPT) codes, modifiers and place of service codes that went into effect January 1, 2017.
Add-on prolonged E/M services
You’ll find a new billing opportunity in 2017 for the work your providers conduct behind the scenes, as the Centers for Medicare & Medicaid Services (CMS) activates two CPT codes—99358 and 99359—that pay for non face-to-face prolonged services.
Codes for prolonged E/M services before and/or after direct patient care are:
99358: first hour
99359: each additional 30 minutes
(List separately in addition to code
for prolonged service).
Keep in mind that these services cannot be reported during the same month as Transitional Care Management services (99487, 99489, 99495 and 99496) or Complex Chronic Care Management services (99487 and 99489). However, CMS has stated that prolonged services “cannot be reported during the TCM 30-day service period by the same practitioner who is reporting the TCM,” which suggests that another provider could bill.
Also, CMS will allow the new code G0505 (cognition and functional assessment by the physician or other qualified health care professional in office or other outpatient) to be billed as an “associated companion code, whether furnished on the same day or a different day” to 99358 and 99359. However, they cannot be billed with the new add-on code G0506.
New codes for health risk assessments
As of January 1, there are two new codes for performance of health risk assessments:
96160: Administration of patient-focused health risk assessment instrument (e.g., health hazard appraisal) with scoring and documentation,
per standardized instrument.
96161: Administration of caregiver-focused health risk assessment instrument (e.g., depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument.
The intent of code 96161 is to capture the practice expense costs of screening caregivers for conditions that may directly impact the health of the patient. Examples include screening for maternal depression at a well-baby visit and screening for stress in caregivers of patients whose conditions may become taxing on caregivers.
As add-on codes, 96160 and 96161 describe additional components of a broader service furnished to the patient that are not accounted for in the base code. Do not report these codes in conjunction with preventive medicine services such as the
annual wellness visit.
Code 99420, administration and interpretation of health risk assessment instrument (e.g., health hazard appraisal), is deleted effective January 1.
New place of service for telehealth services: 02
Effective January 1, a new place of service (POS) code should be used for telehealth services. POS 02 is the location where health services and health-related services are provided or received through telecommunication technology. The service will be paid at facility rate, which is the same way the originating site bills or is paid.
You should report this POS code with modifier GT (via interactive audio and video telecommunications system) or GQ (via an asynchronous telecommunications system). If you bill for telehealth services with POS code 02, but without the GT or GQ modifier, the service will be denied. The top five services billed with modifier GT are 99212 through 99214, 90832 and 90792.
New modifier: 95
Effective January 1, a new modifier is in place: Modifier 95 (synchronous telemedicine service rendered via a real time interactive audio and video telecommunications system) identified with a new symbol of a “star.”
Information on the modifier 95 is contained in the new appendix P: CPT codes with evidence of some payer approval for use when provided via interactive audio and video telecommunications system. Be sure to check with your individual payers.
Requirements for use of Modifier 95: Indicates a telemedicine code:
- Modifier 95: service generally reported as a face-to-face service that is performed via a real-time interactive audio and video telecommunications system,
- Must meet the key components and/or requirements of the code when performed face-to-face,
- Appendix P listing of codes that may be used for reporting synchronous (real-time) telemedicine services when appended by modifier 95. Includes a minimum use of audio and video,
- Identified with the new symbol “star,”
- The appendix does list new patient codes, which makes no sense since all three components are not being met, which is a requirement that the key components be met,
- When asked about this, the American Medical Association responded that the list was compiled by payer survey and if only one payer paid that code with modifier 95, the code was listed.
My recommendation is to not use a new patient code since all three components are not being met.
New CPT code for influenza
While CPT code 90674 for influenza vaccine Flucelvax was effective August 1, 2016, Medicare’s claim processing systems weren’t able to process the code until January 1. If you bill institutional claims, CPT code 90674 will be implemented February 20.
Modifier FX: X-ray taken using film
According to MLN Matter MM9727, effective January 1, claims for x-rays using film must include modifier FX, which will result in the applicable payment reduction for which payment is made under the Medicare Physician Fee Schedule. A 20% reduction for the technical component (TC), and TC of the global fee, of imaging services taken using film.
Note that the beneficiary is not liable for the FX modifier payment reduction.
New cognitive impairment assessment and care plan services code: G0505
G0505 Cognition and functional assessment using standardized instruments with development of recorded care plan for patients 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.
G0505 cannot be billed on same date of service as:
- Behavioral assessment codes (90785, 90791, 90792, 96103, 96120, 96127),
- 99201-99215 (office or other outpatient services evaluation and management services),
- Hospital/Observation same day admit and discharge (99324-99337),
- Home visit codes (99341-99350),
- Medical team conference codes (99366-99368),
- Supervision of a patient under care of home health agency (99374),
- Advance care planning codes (99497, 99498),
- Physician supervision of a patient receiving home health services (G0181-G0182), or
Comprehensive assessment of and care planning for patients requiring chronic care management services (G0506).
However, you can bill the dementia care code during the same billing period that you report chronic care management and transitional care management services. You’re also eligible to report G0505 with the behavioral health integration (BHI) codes that launched January 1.
This service must be performed by a physician or other qualified health care provider. The full list of required elements includes:
- 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,
- 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.
New specialty code for hospitalists: C6
Watch out for a new specialty code for hospitalists going online for dates of service on or after April 1, 2017. Issued November 25, 2016, in CMS Change Request CR9716, hospitalists may identify themselves by the C6 code.
The specialty has certainly been growing: A HealthLeadersMedia analysis suggests 72% of hospitals were using them as of 2014, up from 29% in 2003. Also, the Merit-based Incentive Payment System (MIPS) debuting this year will have a specialty measures set for hospitalists.
There has also been a focus on hospitalists billing only for those chronic conditions that specialists are not. Additionally, medical necessity needs to be met for each date of service, meaning that the visit should only be billed when there is a reason for the hospitalist to evaluate the patient, not when the patient’s chronic conditions are stable.
New abdominal aortic aneurysm (AAA) screening code: 76706
As of January 3, you can forget about AAA screening code G0389. Instead, use 76706 (Ultrasound, abdominal aorta, real time with image documentation, screening study for abdominal aortic aneurysm [AAA]). Patients with a family history and male smokers between the ages of 65 and 75 are eligible for an AAA screening. The patient deductible and coinsurance for these services are waived.