How to use the new Evaluation and Management Codes in 2014

Renee StantzQ: Can you provide more detail about the new Evaluation and Management codes for 2014 and any other CPT revisions that can help our physicians?

A: The four new Current Procedural Terminology (CPT) Evaluation and Management (E/M) codes are for interprofessional telephone/Internet assessment and management services.

These codes are for use by the consultative physician, so they do have some of the same requirements as consultation codes.

Documentation needs to include:

• a written or verbal request by the treating physician or qualified healthcare provider (QHCP);

• the reason for the request;

• a verbal opinion report; and

• a written report from the consultant to the treating physician or QHCP.

To be sure that this information is captured, I recommend that the consulting physician document the request in the patient’s medical record and not leave it to the requesting physician.

So let’s answer some questions about the purpose and use of these codes.

What are they?

A visit billable with one of these codes is a non-face-to-face assessment and management service by a physician with specific specialty expertise and are typically provided in complex and/or urgent situations that do not allow for a timely face-to-face service, such as geographic distance.

Who reports it?

The physician with specific specialty expertise (the consultant) is the provider who reports these codes.  This consulting physician cannot have seen the patient within the last 14 days and cannot accept transfer of care until after the telephone/Internet consultation. 

Also, this type of service should not be reported more than once within a seven-day interval.

Who is the patient?

The consulting physician can bill these codes for patients who are new or established. 

However, established patients to the consultant must have new problems or an exacerbation of an existing problem. If the patient is established, then the consultant can only use these types of codes if he/she hasn’t seen the patient in the last 14 days. 

What is included?

The services included in these codes are a review of pertinent records, laboratory and imaging studies, the patient’s medication profile, and pathology specimen(s). 

Review of these documents may be transmitted electronically by fax or by mail immediately before the telephone/Internet consultation or following the consultation.  More than 50% of the time reported must be devoted to medical consultative verbal/Internet discussion.

If more than one telephone/Internet contact is required to complete the consultation request (e.g., discussion of test results), the entirety of the service and the cumulative discussion and information review time should be reported with a single code.

When is the code not reported?

These codes should not be reported if:

• there is an immediate transfer of care to the consultant;

• other face-to-face services are provided to the patient within the next 14 days or next available appointment date of the consultant;

• the patient has been seen by the consultant within the last 14 days;

• the telephone/Internet consultation lasts less than five minutes; or

• the sole purpose of the call is to transfer the care of the patient from the treating physician to the consultant.

What does the treating physician or QHCP report?

The treating physician or QHCP should report face-to-face prolonged services (CPT codes 99354-99357) if the time exceeds 30 minutes beyond typical E/M time and the patient is present (on-site) and accessible.

Non-face-to-face Prolonged Services (99358-99359) can be billed if the time exceeds 30 minutes beyond typical E/M time and the patient is not present.

Please note that the  Centers for Medicare and Medicaid Services has not given direction regarding reimbursement for codes 99358 and 99359.  Normally, Medicare does not pay for services when the patient is not present.

How are the codes reported?

Only one code should be reported by the consultant, and the code should be based on the time spent for the entirety of the service.  If more than one telephone/Internet contact is required to complete the service, the consultant should report a single code for the cumulative discussion and information review time.

Potential concerns

There are some concerns that providers must keep in mind. The patient/caregiver may not be aware of the service being performed or billed. Therefore, it is important to make the patient/caregiver aware of the service before performing it.  

Also, check the CPT codebook for all instructions and guidelines that are listed before the codes and the parenthetical statements following the instructions.

Payer uncertainty

Payers have not yet stated if they will cover these codes. Make sure to contact your local carriers to inquire about their coverage and rates. 

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

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