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Why medical necessity is key to correct level of care coding


Coding and billing advice from the experts

Q: We are having a disagreement in our office about how to code for a single, stable chronic problem. The doctors insist that it should be a 99213 at least, maybe even a 99214, while our coder says that the decision-making only gives a 99212. Who is right?

a: You have identified one of the major flaws in the medical decision-making (MDM) tables. Not that it helps – but the problem is larger than just your office.
The fact is that the coding tables and audit sheets do not always line up as one might think they should based on knowledge and experience. The root of the problem is that the Table of Risk (table three) lines up with generally recognized medical necessity and common sense (for the most part), and table one doesn’t always do that.
Your coder is absolutely correct that the decision-making tables give a read of Straightforward MDM on a single stable established chronic with a lab (or without) and a prescription medication. Table III describes this as low level decision-making, but Table I does not.
If you look at enough encounters you’ll see that most are coded as 99213s - because they are single-system, stable problems consistent with low risk. Very few payers push back on these, or even comment on them, although Medicare administrative contractor Trailblazer once estimated that 70% or more of all 99213 were over-coded for this reason - and did nothing about it.


If providers do get questioned on this, they usually point to the supporting history and exam and the established patient rule of ‘two out of three’ needed for the history, exam and medical decision-making. In that case, they are essentially relying on the history and exam to carry the code.
Most decent neuro follow-up notes for a periodic assessment of seizure management, or Parkinson’s, or really any systemic problem with risk will have some interval history, large neuro exams, and the patients clearly have significant problems requiring medication management. These should not code out to 99212 or minimal MDM. These encounters are miles from what is meant by a 99212-an ear re-check, contusions etc., and quite inconsistent with the RVU, risk and liability that go with the problems associated with a 99212.
The clinical examples supplement to the CPT manual include examples of a well-controlled migraine maintained on the same medication as an example of a 99213. Although these examples also have some variance, like the federal guidelines, they contribute to the overall body of knowledge on necessity and standards of care.
This is why you need to apply some common sense on these, and not the fixed coding algorithms that the decision-making tables represent. If you think the medical necessity and risk are there, you should give credit for low MDM for one stable chronic with med management of this sort. Remember, Table I is not in the federal guidelines.


Table III is. Your state Medicare program administrators have varying guidelines, and many do use Tables I and II, but these entities come and go, while the Federal rules haven’t budged on these tables in 20 years.  
Medicare has always preached that “Medical necessity is the over-arching criteria for all payments made,” If that is the case – then regard the guidelines as just that: guidelines, and don’t get stuck in counting when it takes you to the wrong place.
Q: The rules for Chronic Care Management (CCM) code say that I cannot bill CPT 99490 along with CPT codes 99495 or 99496 for Transitional Care Management (TCM). If I do perform both services in the same month, and they do not overlap – can I bill 99490 and 99495 for example?

a: You are correct. Both Medicare and CPT state that CCM and TCM cannot be billed during the same month. However, if the 30-day TCM service period ends during a given calendar month and 20 minutes of qualifying CCM services are subsequently provided on the remaining days of that calendar month, CPT code 99490 could also be billed that month. At least one Medicare contractor says “we expect that the majority of the time, CCM and TCM will not be billed during the same month.”
Although you will likely be paid for this coding combination in these circumstances, at least one of the services will be denied when initially submitted and you will need to appeal this and provide clear documentation of the separateness of the services.
Q: Can I bill Chronic Care Management CPT 99490 if the beneficiary dies during the service period? How about the TCM codes 99495 and 99496?


a: Medicare gives clear guidance on the first part of your question and states that CPT 99490 can be billed if the beneficiary dies during the service period, so long as at least 20 minutes of qualifying services were furnished during that calendar month and all other billing requirements are met. Other payers may or may not recognize this.
TCM, on the other hand, represents 30 days worth of oversight in transitioning the patient back to the community from the inpatient setting. If the patient dies between the day of discharge and the 30th day, you cannot have provided 30 days of transitional care.
Remember, if the patient dies after you have performed the included EM visit following the hospitalization, which would normally be included in the 99495 or 99496 code – that visit is billable if you met all the performance and documentation criteria for the EM level you choose to bill.
Q: Does the time to develop a care plan count towards fulfillment of the 20 minutes required for CCM services?

a: This answer also comes from Medicare, so if this is being billed to a commercial plan then you should ask that payer for their policy on this.
Per Medicare, CCM services can only be billed/paid after a patient has been seen by the provider during an AWV, an IPPE, or a comprehensive evaluation and management (E/M) visit. This visit would involve identification of and arrangement for CCM in future months (with fulfillment of CCM requirements).


So the time involved in this initial planning and arrangement for CCM would not be counted for CCM. Instead, this planning/arrangement time would be included as part of that initial evaluation and management service.
In many instances Medicare reiterates that time cannot be counted twice, whether it is face-to-face or non-face-to-face time. So face-to-face time and counseling that is part of a billable preventive AWV, ICCM or other E/M visit is considered part of the prior E/M service and cannot be counted towards 99490.
Time spent by clinical staff providing non-face-to-face services within the scope of the CCM service can be counted towards 99490 as the code description details. Once CCM services are underway, in future months as the care plan changes in response to patient needs, the time spent reviewing and determining the proper care plan can be counted as CCM.

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