Renee Dowling

We are having difficulty billing prolonged services. There are two different codes, and how they are added is different. Can you give us some suggestions on how to manage this in our office?

 Many coding concepts are fairly straightforward and can be left for the physicians to code. However, in my opinion, this isn’t one of those situations. Claims that include possible prolonged care should be reviewed by a coder. This is because there are different codes depending on payer, and the time thresholds are different. Current procedural terminology gives code 99417 and allows providers to add the 15 minutes to the lower time threshold in the range; the Centers for Medicare & Medicaid Services (CMS) offers G2212, which requires you to add the 15 minutes to the higher time threshold in the range.

You should keep in mind the following when billing prolonged services:

The evaluation and management (E/M) code needs to be selected based on time.

Prolonged codes can only be used with 99205 and 99215.

The total time must be documented, and the medical necessity needs to be supported in the note.

Currently, CMS does not require start and stop times.

There are specific elements that can and can’t be counted. I would suggest keeping a cheat sheet of these where you can easily reference it. Look for a description of what activities are included in the time because this is required when using time to select the office visit codes.

A good example of documenting time is, “I spent 90 minutes caring for the patient today, which included reviewing test results, documenting in the record and arranging for follow-up at pain management. It also included an extensive discussion with the patient and his wife regarding treatment options and recovery time, if he decides on surgery.”

Can a medical assistant perform an annual wellness visit (AWV) if a physician or other qualified health professional is in the office suite during the visit?

 Unless state regulations allow a medical assistant to conduct activities that require clinical judgment, the medical assistant would not be able to perform all the requirements of the AWV. Any portion of the AWV that requires clinical judgment (e.g., assessing cognition or discussing risks and benefits of treatment options for identified risk factors and conditions) must be performed by a person whose training and scope of practice include that level of clinical practice. However, a medical assistant can be part of the team of medical professionals providing the AWV services under the direct supervision of a physician, including helping the patient fill out the health risk assessment, if needed.

When reporting my office E/M visits, can I include the time I spent reviewing and confirming my notes when I select the code for the visit?

 You can only count the time you spend completing documentation on the date of the visit. If you review and sign off on your documentation at a later date, you cannot include that time to determine the level of service. For code selection, total time is the time on the date of the encounter that a physician or other qualified health care professional personally spends in activities related to the care of a single patient. This also applies to review of test results on a later date. Although it’s part of the work of the visit, the time spent reviewing test results is not included in the total time on the date of the encounter. Also remember that if you bill based on medical decision-making instead of time, the review of test results would be considered part of the order and not counted separately.

Because we are discussing the time spent on the date of visit, you also cannot include the time spent preparing for the visit (e.g., reviewing the patient’s previous visits, labs or other tests, consultant reports, etc.) on the day(s) prior to the visit.


This article originally appeared on Medical Economics®. 

Articles

What you need to know about prolonged services, medical assistant, and E/M codes.

Your coding questions answered

Question: What are the new documentation codes for 2023?

Answer: The Centers for Disease Control and Prevention (CDC) issued the 2023 ICD-10-CM code 

 on June 9, 2022, which include 1,176 new, 28 revised, and 287 deleted codes to be used for patient encounters and discharges occurring from October 1, 2022 through September 30, 2023. They apply to all insurers, whether you’re billing Medicare, Medicaid, Tricare or a commercial payor.So let’s breakdown the revisions, deletions, and additions to help you get prepared.

An expansion of the dementia codes came from a request in the Centers forDisease Control’s (CDC) September 2021 

ICD-10-CM Coordination and Maintenance Committee Meeting

, the National Minority Quality Forum (NMQF) requested an expansion of the dementia codes to include the stage and severity and identification of behavioral and psychological symptoms of dementia.According to the NMQF, “Both of these clinical elements are major factors in patient management strategies.”As a result, the 2023 ICD-10 code set now includes nearly 100 new codes related to dementia.You’re now able to report conditions like vascular dementia (F01.5-F01.C4), dementia in other diseases (F02.8-F02.C4), and unspecified dementia (F03.9-F03.C4).

The new guidelines for reporting dementia emphasize that providers must clearly document the severity of the patient’s condition. If the documentation is incomplete, the coder should query the provider or default to the appropriate unspecified code. The updated guidelines also instruct that if a patient with dementia is admitted to an inpatient facility and gets worse during their stay, the coder should assign the highest severity level reported during the stay.

, the Committee gave the following clarifications to help determine the dementia stage.

: “Clearly evident functional impact on daily life, affecting mainly instrumental activities. No longer fully independent/requires occasional assistance with daily life activities.”

: “Extensive functional impact on daily life with impairment in basic activities. No longer independent and requires frequent assistance with daily life activities.”

“Clinical interview may not be possible. Complete dependency due to severe functional impact on daily life with impairment in basic activities, including basic self-care.”

A few of the specific new dementia codes include:

F02.811, dementia in other diseases classified elsewhere, unspecified severity, with agitation

F02.A11, dementia in other diseases classified elsewhere, mild, with agitation

F02.B11, dementia in other diseases classified elsewhere, moderate, with agitation

For those providers who see patients for endometriosis or maternal care, there now are almost 400 new codes representing ob-gyn conditions. American College of Obstetricians and Gynecologists (ACOG) proposed an expansion to the endometriosis section of the ICD-10-CM code set, and you will now see many of the new endometriosis codes with further specificity to detail whether the condition is superficial or deep. The definitions below will be critical in choosing the correct code:

: Ectopic growth of endometrial-like tissue that extends 5mm or less below the peritoneal surface. Lesions can vary in number (singular or in multiple locations).

: Ectopic growth of endometrial-like tissue that extends greater than 5mm below the peritoneal surface. Lesions can vary in number (singular or in multiple locations). These lesions are commonly associated with deep fibrosis and adhesions.

If you don’t see the terms “deep” or “superficial” in the physician’s notes, then look for any indication of how far below the peritoneal surface the tissue extended. This will be essential in selecting the right code under the new 2023 ICD-10-CM codes. For instance, you’ll report superficial endometriosis of the right ovary with N80.111, and deep endometriosis of the right ovary will code to N80.121.

ACOG and the Society for Maternal Fetal Medicine (SMFM) also requested new codes for fetal anomalies (e.g. Central Nervous System Anomalies (CNS), Chromosomal Anomalies, and Fetal Abnormalities and Damage). According to these groups, “This proposal will enable better tracking, measurement, and ultimately improved treatment modalities for identified fetal anomalies.”

For concussion and brain injury codes (e.g., concussions, contusions, traumatic brain injuries, blast injuries and hemorrhages), more than 100 new 2023 ICD-10-CM codes have been added in the S06 (

) range.According to the American Academy of Pediatrics (AAP), patients often present with injuries that code to the S06 category without a clear history of loss of consciousness (LOC), so they requested new codes to include identification of the LOC and, if present, how long it lasted.

With the LOC addition, you will need to know whether a patient lost consciousness in order to select the correct diagnosis code.For instance, if a patient had a loss of consciousness with a concussion, you’ll report a code from the S06.0XA series, whereas a primary blast injury of the brain with loss of consciousness of 30 minutes or less will code out to the S06.8A1 range of codes.Here are some specific examples:

S06.0XAA, concussion with loss of consciousness status unknown, initial encounter

S06.0XAD, concussion with loss of consciousness status unknown, subsequent encounter

S06.0XAS, concussion with loss of consciousness status unknown, sequela

You will find a new code category describing poisoning by methamphetamines, as well as codes for adverse effects relating to meth use. In the past, coders reporting meth overdoses had to report these services from the general “amphetamines” category, but use of that code made it challenging for public health authorities to track meth overdoses.

You’ll find new codes in this category under the new T43.65 (

Poisoning by, adverse effect of and underdosing of methamphetamines performed due to self-harm or assault

) range. To report them accurately, you should find in the record whether the overdose was accidental, was, or if the status is undetermined. These factors will be essential in allowing you to select the correct code.

In addition to the new 2023 ICD-10-CM codes outlined above, there are many code changes impacting nearly every specialty. Take some time to review the following:

The CDC comprehensive ICD-10-CM listing can be found 

Renee Dowling is a compliance auditor for Sansum Clinic, LLC, in Santa Barbara, California.

This article originally appeared on Medical Economics. 

Changes for ICD-10 documentation codes that go into effect in October 2022.

New ICD-10 codes to know before October

Question: Can you please tell us what the new codes are for principal care management and chronic care management?

Answer: There are three new codes in the care management section of the CPT codebook.

New CPT codes have been added in 2022 to describe “Principal Care Management Services.” These codes are like chronic care management services in that the work involves the establishment, implementation, revision, and monitoring of a care plan for a patient. However, principal care management focuses on a single condition (rather than two or more). CPT code 99424 describes the first 30 minutes of a Principal Care Management service per calendar month provided by a physician or qualified healthcare professional. To capture each additional 30 minutes of service in addition to 99424, CPT code 99425 would be reported. CPT codes 99426 and 99427 also describe principal care management services, but for clinical staff time directed by a physician or qualified healthcare professional.

Starting this year, Medicare will accept CPT codes 99424, 99425, 99426 and 99427, and discontinue HCPCS codes G2064 and G2065.

A new CPT code was also created effective January 1, 2022, to describe each additional 30 minutes of a chronic care management service performed by a physician or qualified healthcare professional. CPT code 99437 may be reported in addition to CPT code 99491.

Note, there some times when it is inappropriate to bill these codes.

When chronic care management is provided by medically directed staff only (use 99439, 99490)

When less than 30 minutes of time is spent monthly,

When the service time has been reported as transitional care management services (99495-99496).

There are new codes physicians need to know in the care management section of the Current Procedural Terminology codebook.

2022 care management services codes to know

In the medical billing and coding field, getting paid requires accurate documentation and selecting the correct codes. In our Coding Case Studies, we explore the correct coding for a specific condition based on a hypothetical clinical scenario. This scenario involves a patient presenting for a follow-up visit with symptoms of Type 2 Diabetes. See if you can choose the correct codes.

Patient, a 52-year-old male, came to the office for follow up of Type 2 diabetes mellitus (T2DM), hyperlipidemia, hypertension, urine micro albumin. Patient reports he was diagnosed with T2DM at age 45. Patient has been on insulin since 2010. Since last visit, patient reports blood sugars are stable.

Current diabetic regimen includes Tresiba 36 units daily and Xigduo (5/1000mg) 2 tab daily.

Reviewed medication list – medication compliance is good.

Blood glucose monitoring is done 0-1 times daily.

The patient denies hypoglycemia or hypoglycemic symptoms, i.e. no dizziness, sweating, confusion or headaches.

Patient is overweight but generally follows a healthy diet. Goes to gym two to three times per week.

 Positive stocking/glove numbness or tingling. No mononeuropathy. No postprandial bloating.

Retinopathy: Up-to-date on routine surveillance. First diagnosed 1/22/2018.

Nephropathy: Positive. Up-to-date on routine surveillance.

Constitutional/Endocrine/Musculoskeletal: Negative.

HENT: Atraumatic; oropharynx clear with moist mucous membranes.

Neck: supple, normal size thyroid, no palpable nodules.

Cardiovascular: Regular rate & rhythm; no edema.

Neurological: reflexes 2+ at biceps, relaxation phase normal; no tremor.

Type 2 diabetes mellitus with hyperglycemia, with long-term current use of insulin

Type 2 diabetes mellitus with polyneuropathy

Type 2 diabetes mellitus with microalbuminuria, with long-term current use of insulin

Type 2 diabetes, uncontrolled, with retinopathy

Class 2 severe obesity due to excess calories with serious comorbidity and body mass index (BMI) of 36.0 to 36.9 in adult

Hyperlipidemia associated with type 2 diabetes mellitus

When documenting diabetes, include the following:

Drug or chemical induced diabetes mellitus

Diabetes mellitus in pregnancy, childbirth, and the puerperium

E11.65 Type 2 diabetes mellitus with hyperglycemia

E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy

E11.29 Type 2 diabetes mellitus with other diabetic kidney complication

E11.319 Type 2 diabetes with unspecified diabetic retinopathy with macular edema

E11.69 Type 2 diabetes mellitus with other specified complication

E11.59 Type 2 diabetes mellitus with other circulatory complications

E66.01 Morbid (severe) obesity due to excess calories

Z68.36 Body mass index (BMI) 36.0-36.9, adult

This article was originally published on Medical Economics®. 

What you need to know about coding a follow-up appointment for Type 2 diabetes.

Renee Dowling

Articles

Your coding questions answered

New ICD-10 codes to know before October

2022 care management services codes to know

Type 2 Diabetes: Coding Follow-Up Appointments