Coding changes for 2015: New evaluation and management codes explained

What are the 2015 Current Procedural Terminology (CPT) updates that will affect our primary care practice next year?

With an estimated  264 new codes, 143 deleted codes, and 134 revised codes in 2015, now is the time to prepare.  

Thankfully, most of the changes do not affect primary care physicians.  However, the Evaluation and Management (E/M) section does include significant changes in advance care planning, E/M prenatal visit guidance and care management services. So let’s take a look at each of these in more detail.

Advanced care planning 

The two new advanced care planning codes (99497 and 99498) are used to report the face-to-face service between a physician or other qualified healthcare professional (QHCP) and a patient, family member, or surrogate in counseling and discussing advance directives, with or without completing relevant legal forms. 

As you can see, a face-to-face visit is required but doesn’t have to include the patient.  

The CPT manual defines an advanced directive as, “A document appointing an agent and/or recording the wishes of a patient pertaining to his/her medical treatment at a future time should he/she lack decisional capacity at that time.”  

Some examples of advance directives include:

• health Care Proxy,

• durable power of attorney for healthcare,

• living will, and 

• Medical Orders for Life-Sustaining Treatment (MOLST).

These are time-based codes, with 99497 to be billed for the first 30 minutes, and 99498 for each additional 30 minutes.  Because the purpose of the visit is the discussion, no active management of the patient’s problem(s) is performed during the time of these visits.

Additionally, these code(s) can be billed in for  the following E/M services:

• new and established patient office visits (99201-99215),

• observation initial, subsequent and discharge care codes (99217-99220, 99224-99226),

• initial, subsequent and discharge hospital service codes (99221-99233, 99238-99239),

• observation or inpatient admit and discharge on the same date (99234-99236),

• outpatient and inpatient consultations (99241-99255),

• emergency department visit codes (99281-99285),

• initial, subsequent and discharge nursing facility care codes (99304-99316),

• annual nursing facility assessment code (99318),

• new, established and discharge domiciliary or rest home visit codes (99234-99337), 

• new and established patient home visit codes (99341-99350),

• initial and periodic preventive medicine codes (99381-99397), and

• Transitional Care Management Service codes (99495-99496)

However, these codes cannot be billed with:

• critical care codes (99291, 99292),

• inpatient neonatal and pediatric critical care codes (99468-99476), or

• initial and continuing intensive care services (99477-99480).

Be careful: Medicare has indicated that it will NOT pay for codes 99497 or 99498 in 2015.  Check with your commercial payers to see if they are reimbursing for these codes.

E/M prenatal visit guidance

The maternity care and delivery guidelines were revised to specify the following:

• pregnancy confirmation during a problem-oriented or preventive visit is not considered a part of antepartum care. Report using the appropriate E/M code for that visit.

• Antepartum care includes the initial prenatal history and physical examination.

NEXT PAGE: Care management services

The section title of “Complex Chronic Care Coordination” has been changed to “Care Management Services” with an addition of a new subsection, “Chronic Care Management Services” to better reflect the management services described by new code  99490.

The new code requires chronic care management services that take at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month, 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 that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, and

• comprehensive care plan established, implemented, revised, or monitored.

Medicare has announced that it will reimburse for 99490 instead of the initially-proposed G-code, and the Work Relative Value Unit (wRVU) is 0.61.

Keep in mind that chronic care management services of less than 20 minutes in a calendar month are not reported separately. The 20 minutes is in contrast to at least 60 minutes of complex chronic care management service that would be reported by a code 99487.  

Also, the add-on code 99489 should not be reported for service of less than 30 minutes in addition to the first 60 minutes of complex chronic care management services during a calendar month.  

According to the American Medical Association, in addition to the above criteria for care management services, the requirements for complex care management services include:

• establishment or substantial revision of a comprehensive care plan,

• moderate or high complexity of medical decision-making, and

• 60 minutes of clinical staff time directed by a physician or QHCP per calendar month.

Patients may be identified by practice-specific or other published algorithms that recognize:

• multiple illnesses,

• multiple medication use (and potential for drug interactions),

• inability to perform activities of daily living,

• requirement for a caregiver, and/or

• repeat admissions or Emergency Department (ED) visits.  

The answer to the reader’s question was provided by Renee Dowling, a billing and coding consultant with VEI Consulting, in Indianapolis, Indiana. Send your coding and billing questions to medec@advanstar.com.