Bill Dacey, MBA, MHA, CPC, CPC-I

Several of our primary care providers are billing transitional care management codes 99495 and 99496. One of our coders tells us we aren’t doing these correctly, and sometimes we shouldn’t bill them. Can you give us a heads up on the problem areas here?

 Certainly, there are very definite areas where providers go astray with these. For both the 99495 and the 99496, the first thing providers need to remember is that there are two principal criteria that need to direct their code assignment once they have decided to use a TCM code. These are the time window of 7 or 14 days after discharge applying to the 99496 and 99495 respectively, 

We see many providers bill a 99496 when they see a patient within 7 days, but that patient is nowhere near high level decision-making, or it isn't documented. Even if it's within the seven days, if the decision-making is only moderate, it becomes a 99495.

Providers also sometimes code 99496 based in part on the severity or acuity of the event or circumstances causing the hospitalization, (i.e., stroke, MI etc.), versus the status of the patient the day they are seen. We see the hospital history in the HPI, but the A/P describes f/u by Neuro or Cards, the problems are resolved or stable, and they don't say much about the status of relevant chronic conditions in the A/P. Sometimes these cases fall right out of the range of TCM codes altogether.

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not all hospital follow-up encounters qualify for a TCM

. In the case above, where the provider might describe a single issue followed by another specialty, you'd only get a 99213 out of the visit unless it was based on time. 

, since the intent of these codes is to prevent re-hospitalization within 30 days, and they are intended to cover all issues relevant to the patient's safe return to the community, the A/P should include the Dx, status and Tx/Rx for the significant co-morbid or chronic conditions to make sure the bases are covered to promote a strong recovery. And you know that sometimes certain drug regimens are altered by hospitalists and need to be re-configured. The medication reconciliation is a required component of the TCM codes, and it must be documented. But you should also show those problems that are specifically addressed, considered, or assessed.

Some hospital follow ups just shouldn't be assigned a TCM. Healthy young adult spends a day or two in house, short course of something, goes home. Comes to see you a week or two later for f/u - nothing going on, resolved or stable, no other problems - it's a 99213.

Read More: CMS 2021 Final Rule: What practices can do

And always clearly document the medical decision-making that represents 

That covers most of what causes problems with these codes. I'm sure there are some minor variations or permutations of the above - but if they get all that right then you'll likely be at 95% correct on these

The issue of 'do you qualify for' a TCM re the patient contact piece is much more of an operational issue, with many pitfalls, and isn't as much of a coding issue. We’ll leave that to a later time.

, MHA, MBA, CPC-I is principal in The Dacey Group, Inc., a consulting firm dedicated to coding, documentation and compliance concerns for physicians. Bill is an evaluation and management (E/M) coding expert and has been active in physician training for more than 25 years. He can be reached at 

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There are two principal criteria that need to direct physicians’ code assignment once they have decided to use a TCM code.

Coding Q&A: Problem areas with 99495 and 99496

 I am pleased to bring you this second installment of our Coding Q&A podcast series. 

In this Q&A, we look at two submitted questions from our viewers. The first inquires about problem management credits—specifically, who will retain credit for problem management in new CPT codes in 2021; the second question deals with what notes are required and beneficial in A/P notes for AWVs.

Our first submitted question today concerns upcoming changes to the CPT Manual. Specifically, this individual is asking about ‘problem management’ changes. They wonder: “Is it true that physicians will no longer receive credit for assessing problems when a specialist is involved in their care?” The questioner says that this hardly seems fair…

Ah, no, that's not entirely true. And this provider is certainly not the only one who's wondering about all the upcoming changes to the to the CPT manual and specifically the E&M codes because we haven't seen changes like this and, you know, over 20 years really.

But his question is, “Do we not get credit for Problems are assessed when a specialist is involved in the care?” I think the reason he's probably asking about that is that there is one of the things that the AMA released, that tells you that, you know, unless you have some additional assessment or a care documented, when it comes to listing problems that are managed by others, unless you can show them that you did something, they're really not interested in paying you for this.

And let me just kind of set the context here a little bit. This comes out of the guidance to the E&M guidelines for 2021 that the AMA has released. One of the things that they did was they've redefined what problems are, what problems count, what problems count towards your level of medical decision making. They had made this comment and it was actually a good observation. It's something that people have been wondering about over the years because you'll see a note that says the patient's here for chronic disease follow up or chronic disease management. And they'll give you a little bit of status of a couple of problems in HPI—that pressure, blood pressures or blood sugars, et cetera, et cetera—but when you get down to the assessment and plan, you'll see something about the hypertension, you'll see something about the diabetes with Olympus.

And then you'll see a comment that says, you know, CKD, chronic kidney disease, three, managed by nephrology, or we'll just say CKD3, sees nephrology.

Now, you know, we don't really need that problem in there to get this code to a level four because we've got maybe three problems before it, but if there's only three things listed and the first two are stable issues, and CK3 sees nephrology, we've always wondered whether we were counted that or not because it's more of a comment. than anything else—more of a mention—the physician doesn't really seem to be engaging, you know that problem, he's pretty much saying “Nephrology is taking care of this.”

So, that questions been around for auditors for many, many years. And I think physicians being trained to code based roughly or usually on the number of problems that patients have, you know, would tend to include these things because in their mind, certainly someone with CKD—chronic kidney disease level three—and hypertension, there's an interplay between those two things and they each make the other more complicated. And it's a very real thing to them. But what the AMA is saying is unless you kind of show us that this comorbidity that's out there or this other problem, that you're kind of assigning or giving away to somebody else, unless you can show us that there’s some work that you're doing today that goes along with that, they're not really interested in in counting that.

So what you need to be really careful to do is to kind of again, show your work and say “We did a, a GFR test today or GFR”, give that score in the albumin score, maybe—because I'm sure there's labs that pertain to the CKD—and maybe mention the way that that relates to their hypertension and your choice of medications.

You need to say something in there before you say something as simple as “sees nephrology or will see nephrology next week”, because you're in effect, just kind of giving it away. And you're now kind of on notice that unless you sort of show that work, it's not going to be counted towards your level of medical decision making.

So, in a way, it's a long overdue clarification of something that's always been a little unclear. And I guess it's also kind of noticed to physicians that hey, you know, we were happy to count comorbidities and other things that are going on, as long as you show us how it impacts your level of medical decision making.

So, it's good news in a way, the way that the question was read was kind of like, “What do you mean, I'm not getting credit for that?”

 You know, that's understandable, too. It was just the way I think it was worded that kind of made it sound like that.

I think the guy said it hardly seems fair, you know that that wouldn't count. And it only doesn't count if you really aren't doing much. I mean, you know, we see that a lot with “sees cardiology”, “sees card”, “sees pulmonology”. And if you are kind of just saying that those problems are managed lock, stock, and barrel by somebody else, or being met or addressed by someone else, then you probably shouldn't get credit for it. But if you can show how that impacts your work, then it's all to the good.

You know, it's still going to be, I think all about counting—counting problems, that nature of problems. There's another kind of a one-liner in here that relates to that, where they tell you that, you know, simple referrals to someone else aren't going to be counted either. And that's another case where, you know, all of those situations aren't the same.

If a patient comes into you and the HPI says they're here for a referral to OB for something or other. And then down in the assessment and plan it says, referral provided to OB and there's really no mention of the even the OB issue, that they're not going to count that.

If the patient comes in with a complaint or a problem of bleed or You know, some kind of a symptom, that's OB nature, And you ask questions about it, and you do an exam, and then you get to the assessment and you plan and you say, you know, “we found this and such, we're going to order this in such a lab, but we're also going to refer it to OB to see what they think of it,” that's a completely different animal, because you've worked that one up. You know, you've kind of done what you think you can do? And your answer is I think we better have a specialist look at this, as opposed to somebody who just walks in the door and says, I need a referral to so and so for because my health plan insisted on that.

So, that's another case of the AMA clarifying things where they kind of say referrals won't count. But you have to take into consideration the circumstances because they're not all the same. Some of them are the easy version, and some of them are the after some workup, we've decided that that's the answer.

There's a whole lot of things that are in that release or prerelease, if you will, that the AMA put out that physicians are going to have to get used to, in that assessment and plan because as I said, that the new rules in 2021 are going to be that you can code by medical decision making, or you can code by time. And setting time aside for the moment, you know, the decision-making pieces still going to be about the number and the nature of problems and now they're making it a little bit more clear that they want to know the extent of your involvement.

You know, it's long, not been enough to just name things you know, they've always wanted you to say “stable, continue this inside or worsening or exacerbated or progressing,” But now you in some circumstances, you may need to do a little bit more. And if you don't mind me just kind of going forward with this a little bit only because I know that this is still in the same sort of spirit of what this person is asking. You know, there's new language that physicians are going to have to kind of get used to, I think one of the more important ones.—when I first saw it, it really rang a bell with me—is that the AMA made it very clear that a problem that is not a goal is not considered to be stable.

And what's kind of interesting about that is that, you know, your previous choices to describe problems that weren't stable, the ones that they kind of offered you up in some of the language and CMS shared that same language was, you know, “worsening”, “exacerbated”, “progressing”, “poorly controlled”, “uncontrolled”, that kind of thing. Sometimes physicians set it, sometimes they don't, you know, we always recommend that they do. But there are some problems that they're not really worsening, they're not really uncontrolled, but they aren't where you want them. You know, they're not at goal, not really where you need them to be. And until they came out and said that, you know, that problems not at goal, equal kind of problems that are worsening or exacerbated, or actually what they said was if they're not stable, which pitches them into the other camp of the, you know, poorly controlled, uncontrolled, et cetera, et cetera. So those are going to be counted as you know, two brownie points, if you will, the way that they were that they score those things, as opposed to one.

So that's another kind of set of language or words that, you know, providers are going to have to get used to, but it's an important one because it happens pretty regularly. You know, it's not unstable. But it still requires work. It might require additional medication, it might require changes in medication, and it's just not what the easiest version of describing it might be. So I know that was a lot for that one question, but it all seems kind of related to me.

 The second question we will look at today concerns combination of AWVs and problem vists in the same encounter. This questioner’s staff apparently tells this individual that he or she is not documenting to support both, despite the questioner saying he or she includes problems addressed in the A/P section.

They are at a loss as to what else they need to include. What are your thoughts and/or suggestions?

Okay, you know, once you say the word combination visit, and there's lots of names for this split bill and all that. And I think we've talked about this before. I think we talked about this, maybe even in the last session, but there's many opportunities for things to go sideways here. And I think the last time we talked a little bit about the importance of naming things and making clear that you know the patient is presenting for their annual wellness visit and management of XY&Z etc, etc.

So, this provider kind of says, hey, my office staff is telling me I don't have enough for two codes—here, preventive and Problem Management—but I have a good assessment and plan, which is really where you'll see the problem management port, you know, what else do I need, I think is what he is he or she is saying.

And it's a good question, especially in light of where we're going in 2021, because it kind of gets a little mysterious that it's easy to answer right now today, and I'll answer that. The other piece that you need is the HPI. And part of the reason I say that is that you've always kind of needed two components of a E&M visit to qualify for the code for an established code —history exam, decision making. We know that decision making always needs to be one of them to kind of keep us rooted in medical necessity. But really what goes with chronic disease management or follow-up, which is typically what happens along with an annual wellness visit, they just want that same little HPI that you do on a 99214 that says, you know, hypertension pressures in the 130s, lipids, whatever, diabetes, whatever. It's, it's part of Medicare and other payers’ way of determining medical necessity, that up in the beginning of the note, we're here to do these different things. Here's a little bit of the, I like to think of it as the before and after, you know, before this visit, this is what's going on with these three problems. And then after study and after some discussion and some exam, this is kind of the answer down there in the assessment plan, but that gives Medicare and other payers are very warm and fuzzy feeling that it is what it represents itself as here's a little bit before, here's a little after we've taken a good look at this problem or these problems. And here's what we're going to do about it very much demonstrates the management.

So, I don't know what this person's notes look like. But if their staff is saying there's not enough, and physician is saying that their assessment and plan is good, then really kind of the only thing that can be missing is that little HPI front and very clear documentation that they're here for two things.

The reason that I said that this gets a little murky going forward. I'm really curious about this. Maybe you've been a little worried. Only because I've been in this business for a while. They're not my charges. I'm not going to lose any thing you know, if this doesn't work well, but it just it just hurts my feelings a little bit I guess if we're leading people into uncharted waters, so to speak.

But since the 2021 regulations say that you do whatever history exam you need to do, and they're no longer going to be counting things like HPI and review systems and physical exams, and it's actually actively being touted by CMS “patients before paperwork” and “less documentation” and all of that, that this is exactly the place where physicians might say, “I don't need to write that stuff anymore. You know, I don't need to do that little HPI anymore. All they're looking at is the decision-making piece. coding is based on decision making. So as long as my HPI is, as long as my assessment plan is good, then I'm good to go.”

I think that's a mistake because of what I had mentioned before, the payers need a little bit of context for that those problems that appear in the system assessment and plan, they can't just appear there for the first time.

In the note, if there is no kind of advance warning, I think in prior conversations or articles or questions, you know, we've mentioned that the payers kind of used that HPI like, almost like a table of contents for, you know, what's this visit about. And so if they're not expecting it, if this these things just kind of appear in the assessment and plan, I'm not sure that you've done a good job of documenting the separate and significant nature of that additional code, because remember, the whole scenario here is just that you're billing them for two codes, you've got your hand out twice, I want to be paid for this one, I want to be paid for this one. And the 25 modifier that you put on there when you build two things, says that this is a separate significant and identifiable other service. And so now there's some discussion about well, you don't really need to do the history part anymore, so how much of the separate and significant, you know, went just went out the window.

So that's the part I meant when I said I worry a little bit about this is if people kind of back off or slack off on their documentation too much. Probably the last place you want to do that is the HPI. It's long been the case that the two sections of the chart where physicians need to document you know, specific patient-specific narrative information is in the HPI and the assessment and plan—the EMR can't write that for you, it doesn't know whether something is shooting, stabbing or throbbing, it just doesn't know. It can pull in the past family social history, you can pull in big canned exams, you can pull in big giant can review systems, but it can't write the HPI can't write the assessment and plan.

So I think it's really important and goes back to this question that you remember that that HPI is a little more important than just a piece of the documentation guidelines, it serves as an outline. It serves as the before versus the after that you'll see in the assessment plan. So again, that's, that's kind of my read on that one. Although I don't know what this person's notes look like. It could be dismal. And their staff is right, and they shouldn't build for any of that, you know, but some of it, you just can't tell unless you look at their notes and see what they actually have out there.

But that's the I think the thrust of this question is that, you know, you need to make sure that it's your work is clear, you know, don't abbreviate it.

I said this once years ago, I think in a one of your articles: if you abbreviate your work too much, the payers will find a way to abbreviate your payment. And so, you know, just remember that. Efficiencies great and less keystrokes are great, and it's wonderful let defense have taken away the requirement for a lot of thebig bulky EMR stuff that's contributed to a lot of just junk in the in the note, but don't take away the stuff that is important. And the HPI is going to continue to be important, even if it's not required.

Thank you so much again Bill, your information and insights are always greatly beneficial and appreciated.

And thank you all for listening to this ninth episode of Perspectives, brought to you by Physician’s Practice.

We hope you subscribe where you listen to podcasts, rate us, and let us know what topics you would like to hear more about.

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Coding expert Bill Dacey, principal of The Dacey Group, answers viewers questions in this second installment of our Coding Q&A podcast series.

Coding Q&A Podcast 2: Problem management credits; A/P notes for AWVs 

I’m an internist after a review of these new 2021 guidelines it looks like it might be easier to code 99214’s than it is now. Does it seem that way to you?

A1. That’s a big Bingo there – the new Decision-making tables give you at least two very clear pathways to 99214’s for scenarios that previously would have been ‘counted’ as 99213’s or low level decision-making.

Before we give you the easy new instruction, let’s outline the mechanism at work here. Currently there are three decision-making tables. The first of these tables contains the indications such as one stable chronic problem valued at 1 point or minimal decision making (99212) , 2 stable chronics would be low (99213) and three stable chronics would score out to moderate (99214).

Table 3 has always (since 1994) had ‘two or more stable chronic problems’ assigned to moderate level decision-making. But you needed two of the three tables to match. So presently these tables are offset somewhat – Table 1 scores two stable chronics as a 99213, Table 3 score it as a 99214. With Table 2 (Data) set aside for the moment, two stable chronic issues here in 2020 scores to Low level decision-making or a 99213.

But in 2021 Table 1 is no more. The old column one from Table 3 replaces it – so there is no longer an offset. So as long as one or more of the problems assessed is being managed prescriptively – two stable chronics becomes moderate decision-making.

This will make a huge difference is the coding profile. It will of course vary for every provider, but how many of your presentations are patients with two stable chronic problems, managed prescriptively? Ten percent, twenty percent?

And this isn’t the only place this happens. With Table 1’s departure goes the difference between ‘established’ problems and ‘new’ problems – at least with those labels anyway. The new 2021 Column one does reference ‘undiagnosed new problems’ under moderate, but other than the injuries or illnesses that are acute and likely new, the idea of ‘new’ and ‘established’ problems is gone as a specific attribute of problems.

That change moves a single worsening chronic problem from low to moderate, or 99213 to a 99214. In 2020 a worsening chronic on Table 1 was low, and moderate on Table 3 – a 99213.

Now we have moderate in Column one and as long as there is prescriptive management involved – it’s moderate in column three as well. This picks up all your worsening, exacerbated, poorly controlled, uncontrolled, inadequate response to treatment and the new label ‘not at goal,” which for Medicine will most often result in an adjustment to meds either in dosage or a change in regimen involving other agents.

So, in 2020 you’d need one stable and one worse to get to a 99214 with established problems, in 2021 – one worsening with Med changes does it. What percentage of encounters is that?

And this bounty extends to 99215’s in at least one instance. Similar to the example above with a worsening problem – what if it is a ‘severe worsening or exacerbated’ problem that involves ‘a decision regarding hospitalization’. Per the 2021 Table that scores a 99205 or 99215 by Column one and Column 3 with those exact indicators -one established problem.

Our estimate was that the new CMS plan was going to benefit providers in terms of EM profiles even when they were planning to ‘combine’ payment levels. But the details in the tables as written for 2021 allow for a significant shift to the right in coding profiles, and associated revenue, without doing anything different. Same work, more money. Any takers?

2021 EM guidelines turn some traditional 99213s into 99214s.

New coding guidelines a recipe for improved revenue

Today we are featuring the first of our discussions with Bill Dacey, President and CEO of The Dacey Group and one of Physician’s Practice's Pearls contributors.

Twice a month, Bill answers readers’ top coding questions in his wildly popular Q&A columns.

With the advent of MJH Life Science’s video and podcast programs, both of which can be access from Physciain’s Practice’s site, Bill has been gracious enough to sit down with us for supplements to his regular columns.

In this episode, we are taking a look at questions regarding mixing provider types, protocols, and patient behavior.

Our first question concerns Medicare new versus established patients.

A patient is seen in the ER, treated, and released. At a later date—within three years—the same patient is seen by one of the system’s providers who is also credentialed as an ER physician in the clinic for wound care. Although wound care is not considered a specialty under Medicare guidelines, would the patient still be considered established since the provider is credentialed in Emergency Medicine?

This one's a little tangled up just has a few pieces in it. You know, when you get into taxonomy codes and different specialties, in part it depends on the payer. How does every individual payer have every individual provider credentialed or assigned to certain specialties within their system?

You know those taxonomy codes that CMS puts out? I think they originated with BlueCross BlueShield. But not every payer kind of sees every provider the same way. So really, these are two quite separate incidents. Obviously, you've got an ER visit and then you've got a wound care visit some time later. And once all the smoke clears, there really shouldn't be any problem getting both of them paid because even if the physician in question only had an ER taxonomy or designation, if they've got or demonstrated expertise in another area—and you'd probably have to write a letter, this isn't going to be a clean claim, possibly—Medicare or the payer will eventually see the light and say, “Okay, this was a wound care case. And you know, even if we do have the taxonomy codes mixed up, this is a payable event.”

it's within three years, is it established? That's the question that the CPT definition reads—seen within the last three years, same exact specialty, etc. And have you seen the same physician? So yes, it's the same person.

So it's going to be established, but you're probably going to run afoul of the taxonomy things and have to write a letter would be my guess.

 The second question we will look at today involves patient is seen in the hospital or in an office as a new patient under the mid-level. This practice bills the hospital initial visit or office new patient vists under the mid-level only, without supervisor (i.e. not incident-to). The mid-level meets with their supervising provider and comes up with a plan of care for the patient. The patient then has a follow-up visit with the mid-level. 

Since the patient has still never seen the provider, but the provider created the plan of care, can the follow-up visit be billed as ‘incident-to’?

So, really what you need to do, again, this is going to be a potentially payer-specific thing. I would say the mainstream answer is that it could not be billed Incident-to, it would have to be billed under the mid-level’s name because the physician never actually saw the patient.

I recognize that the plan of care is an important component billing Incident-to and that that's one of the requirements for those subsequent incident visits—that you're following up on the physicians plan of care—but I think if you walk through the little tests that the various Medicare payers or contractors have online about, “Does this meet incident two criteria?”, you'll see that it will say something about “Seen by the physician and then their plan of care.”

So, even if it doesn't exactly say it somewhere in a guideline, all of the kind of ancillary evidence is that the expectation is that the patient has been seen by the physician who established a plan of care. This is a little bit off from that and it sounds like more non-physician practitioner work than actual physician work, even though there's a shard of that in there.

RVUs: The basics of physician compensation

 One problem that recurs in this next questioner’s practice is that, when the billing clerk tries to determine tele psychiatry codes, video+voice, most providers aside from United Health give the same reply:

 “We can’t advise you as to how to bill….”

Providers refer this practice to their website, each with their own complications and level of development, but each insurance carrier seems to have different codes/modifiers. This leaves the billing clerk hoping for the best in nearly every situation.

Any suggestions would be greatly appreciated!


You know, this question sounds like it's just kind of about getting paid. I'm not sure what I guess all questions are about getting paid. Coding questions anyway, or billing questions.

 But, you know, the payers have adopted this perspective or it's almost like a mantra these days. That, you know, they can't tell how to code something. And, you know, Medicare has been doing this for years, this person, I guess, mentioned United.

But you know, they can't give you the formula to get a claim paid. I mean, the whole idea is, is that you use the CPT manual and the ICD 10 system to report what you did.

So, you have to craft a little communication to your payer in every case that should have the combination of what you did. You know, why did you do it your ICD 10 codes, all the little bells and whistles modifiers and whatnot that you need to properly identify to the payer, you know, all of the circumstances surrounding that encounter.

If you have a question about how modifiers work, you just need to figure that out. They're just gonna pay or not pay what you send them. You can't call them up and say, “Hey, if I configure it like this, will you give me a lot of money? If I configure it like this, will you give me more money?” I mean, that's just kind of an invitation to racketeering and fraud. And, you know, they just won't do it.

It's a reasonable kind of a platform that the papers have that say, “Well, we can't really tell you how to code something.” I mean, a, you're the one who did it. So you just need to learn, you know, your how to report things.

If something bounces off, if something is deflected—or denied, or delayed, or diminished, or whatever they do, (and they do all of those things)—then you just have to refile.

You know, if you think you've got something wrong, you have to really pay attention to the denial. That's what it's all about, you know, why did they say now? A lot of people just say, “Oh my gosh, they said no to me and they slink away.” And that's not what you want to do at all.

A denial to a health insurance company, that's just the beginning of a conversation. It's certainly not the end.

So in terms of advice to this person, no, they're never going to tell you how to code. They're just going to say yes or no. Or partly, and you just need to use the tools to, you know, communicate with them in the coding and billing language that they communicate with.

 In our fourth question, a patient is seen by a midlevel in an Endocrinology practice and the patient is a ‘hot mess’. She sees the patient and evaluates them and then sends her MA into the exam room to go over how to use insulin or whatever. This ends up taking the MA 30-40 minutes.

Prolonged services cannot be billed for anything less than 30 minutes, but can the practice bill for prolonged services when extra time is being provided by the MA not the billing provider?

They would bill for 99214 based on documentation and medical decision making and then 99354 for additional time the MA takes with the patient.

That's a big No. Also right out of the gate know, when you're dealing with time-based codes—or many time based codes, certainly from a Medicare perspective—it's the time that the patient spends with the physician or the nurse practitioner or the PA, you know, that whole concept of incident to is more about wrapping the whole visit under the supervision or auspices of, you know, kind of head provider if you will.

But when you start saying “Alright, I'm going to do this and then I'm going to hand it off to so and so. But I'm going to keep billing as if it's me.” If you say it that way, it doesn't sound quite as good. And the AMA doesn't have the ability to report services in his or her own name. They're not really reportable services. And so, you certainly couldn't run the prolong service code on that.

CPT didn't help that. Some years ago, those codes used to say face-to-face with a physician or other qualified health care provider. And then a couple of years ago, they changed it to ‘direct supervision’. So, we weren't entirely sure what that meant, but when you kind of play this question against the larger backdrop of regulations, pretty quickly, you get to the part that I just said about how you You don't build at the physician rate for the work that someone else is doing.

So, the physician would get their nine, nine to one four here, but they wouldn't be able to tack on that 99354 for the time that that ma spent with the patient during other teaching things.

Improving coding processes to achieve value-based care success

 In this next situation, Dr. A and Dr. B both rendered services to the same patient the same day and both subsequently billed for their respective services. One was an actual office visit, later in the day a telehatlh video visit. Can the services be combined and uploaded? The asker says that their biller says they can absorb one of the services into the other and possibly bill for a 99214/99215.

That's more good creative—somebody in the office thinking oh, you can just add them together apples and oranges.

 It's another interesting question. The general rule of thumb and this CPT rule is that you're only going to get one E&M per visit, per day per group per provider type, that kind of thing.

So, if somebody saw someone in the morning, and then somebody saw someone else later in the afternoon in the same group, you know both those claims went out, it would get denied. Same provider, same days, same specialty, you know, the first one that gets there gets paid, the second one doesn't.

What you pretty much need to do is add them together, like this person said, and file one claim. A couple of things come up in here. Number one, physicians are, over the past few years, even more cognizant of their own RVU production and what did I do today and what does it look like to the, you know, administrator or the group leadership? You know, they need to put their points up on the board, what did they do? So, Dr. B may not really be so interested in just saying “You know, take whatever I did and just you report it under your name and you take the money, you know, and the RVUs, that's good.”

You know, if it all comes out in the wash, and everybody kind of agrees that, you know, this happens to me is obviously happens to you, you know, maybe that's not a problem.

But kind of the other issue in here is it These were two different visit types was one of them a, an office visit, and the other one was a was it a phone call? Or was it a video?

 Okay, so that would have, in the current public health emergency, qualify for use with those offices, it codes and now you're kind of tracking to do that to have the same codes again, which you don't want to do.

So, this brings up even more, you know, how do you add it together questions: do you take the totality of the history exam and decision making and sort of glue them together?

And you could do that. But the documentation is not really going to look like that. Unless somebody has some kind of foreknowledge here. The second person would have to be kind of aware that you had this first visit, and kind of build their note around that. They may be referred to the earlier, you know, physical exam or whatnot, and maybe refer to some of the decision making elements that happened before and they would have to kind of package it with all of the pieces in it.

Because what a payer isn't really going to be interested in doing is taking this apple and this orange from over there. 213 and a 213 and adding them together and magically coming up with a 214—that's not really gonna work.

Probably the best way to do it would be for the second person to talk about time—total time in both encounters—but again, the first person doesn't know that there's going to be a second visit, so they may or may not say anything about timing might not how long know how long that is.

It's just an awkward set of circumstances. And each one of those would have to be kind of handled the way that you could handle it. Sometimes when you try to kind of retrofit documentation into some code structure that you want to put out there, it's not a good fit. It's just going to look right, because, you know, people weren't thinking that way when they wrote those notes.

So yes, you can probably, maybe get a higher level of service out of that. But there's probably going to have to be an addendum somewhere along the line and one of the docs is going to have to give a little ground That’s not a perfectly clean answer, but those are the considerations.

 Our final question for this episode concerns HHC code capture in the note. When an annual wellness visit is performed, this physician often adds the HCC at the end to increase RAF score. Their auditor said they can’t do this if they don’t actively manage these things. Is there a way to do this legally? 

So the office manager said don't just list HCC scores in the assessment plan when you're doing an annual wellness visit that provider or someone wants to know but I want to and so how can I How can I do this?

So the coder or whoever it was is right that you know a list of codes a list of diagnosis codes at the end of a note in the assessment and plan isn't really what the HCC and RAF scores are all about.

Physicians do confuse those things on a pretty regular basis. You know, they're responding to requests from administration and coders and payers and everybody else to report all these codes report all these codes, make sure we know how complex the patient is every year, you need to tell us all of the patient's problems. And so that probably sounds to them, like if give me a list of codes, but what those what's really behind that and what's behind that whole payment system is they want you to evaluate each of those problems in the course of the year or to tell them how many problems needed to be evaluated addressed in the course of the year so that they can properly kind of assemble that total fabric, if you will, of the patient. You know, how complex are they how many, how bad how often all that.

But just naming things and just a list of diagnosis codes, that's not that's just a list of diagnosis codes. I mean, you could kind of copy the problem list and stick it down there too

A.) You can't typically address all of the patient's problems if they've got any complexity at all in one visit. Certainly, if the visit is an annual wellness visit, and then maybe some Problem Management, you can't do all of them, you know, that visits going to get pretty long.

So let's stay there. question is, is there a way to do this legally? No, there's no, it's not correct to just give them a list of diagnosis codes.

If you want to lay claim to the HCC assessment portion of a problem, you know, that I looked at this this year. The trick there really is to assign it a status. It's the same way that the E&M codes the decision making works with the new medical decision making guidelines at the AMA just came out where there's a little bit of discussion about what constitutes problems constitutes whether a problem has counts today. It really hinges on some kind of evidence that the physician evaluated or assessed it and how do we know that it? it's characterized as you know, stable, well controlled, improving, you know, continue with, you know, nephrology, whatever it is. That last one might not count, because if you're not managing it, but for HCC purposes, you know, that code is now in there and we know what's going on, it's being managed by nephrology.

So, I would say, to try to straddle the fence a little bit. If you are really interested in reporting HCC codes, and it's because you have assessed some of these problems or have something to say about them, then you can just add a little section in your assessment plan underneath the annual wellness visit. portion that says, you know, conditions, you know, address today or conditions assessed today and list them and give them some sort of assessment or evaluation or characterization, if you will.

I see physicians write problems not addressed today, and they just give a big long list of things. If a third-party payer, if risk payer wants to take that list and credit you with that, why then, you know, bless them, but that's not really what the, program says it's looking for the status or problems. So, I would say that that's kind of a now you can't really just give a list and get credit for it. The trick there is to either you're saying something about those problems or you're not.

I would encourage you know, physicians to get on board with this characterization or, you know, describing problems as stable, improved, worsening, etc. It's always been the core of the decision-making piece and that's now going to be not just in the front seat, it's going to be the only thing that payers are really looking at come January 21st. With the change in the E&M guidelines, they're just going to be looking at decision making. It's actually a federal rule that, you know, for an established problem, you have to say it's part of the documentation guidelines, whether that problem is stable improve or worsening, etc. And, you know, even to preserve levels of service, you know, that's kind of in there, too, is it mildly exacerbated,wildly exacerbated, you know, that might be the difference between a four and a five

Som that language is tremendously important. And there's a, I would say, a pretty systemic over reliance on computer generated lists of codes, when what they're really looking for is, you know, how bad is this? You know what, what is going on? On this problem, that's what they really want to know.

Thanks again, Bill. That sums up our questions for this first podcast edition of Bill Dacey’s Coding Q&A.

Thank you all for listening to this seventh episode of Perspectives, brought to you by Physician’s Practice.

Bill Dacey, president and CEO of The Dacey Group, pens the popular Coding Columns on Physician's Practice. In our first podcast version of this column, we answer contributed questions on provider types, protocols, and patient behavior.

Coding Q&A: Mixing provider types, protocols, and patient behavior

I’m trying to come up with a statement I can use to document time I spend on hospital patients. Can I say, “I spent ___[X]____ minutes on the floor examining ___[Y]____, talking to the family, and placing orders”. Can I say, “MDM time,” which the ER physicians say in their notes?

 You are on the right track, but I’d suggest you say something a little different, now and in 2021 as well.

Although the definition of hospital time for coding purposes is described as 'floor time' that’s not really the part that needs to be spelled out. Like the 'counseling' time in the office, for inpatient time you need to document that over half of the total time was spent in either 'coordination of care' or ‘counseling’ and document what the total (floor) time was.

At minimum you need to say, “Spent over 1/2 of XX minutes coordinating care with A and B and C regarding X, Y and Z”. It's not a good practice to generically say, “coordinating with the rest of the team”, or “talking to the family, placing orders”. Instead, say “working with the social worker to arrange discharge” or “speaking with Mom and daughter about plans to do this or that ....”. That's the right way to do it. 

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Medicare, in particular, doesn’t care for generic time comments—these need to be personalized to the patient and the circumstances, and support medical necessity. 

And the “that's what the ER docs do” comment is a bit baffling—ER professional codes have never been able to be coded by time. No guidance ever suggested that the 'time' be linked to that spent on decision-making. That concept seems to be a mix of several guidelines that don’t take you there. Only during the pandemic were ER docs, like everyone else, allowed to code by MDM alone, and that was for telehealth visits only.

Remember that although the outpatient guidelines change in 2021 to eliminate the need for the ‘counseling or coordination of care’ aspects of coding by time, the inpatient codes are not impacted by this. The earliest that that could happen would be 2022, and that’s unlikely.

I have a question about medication reconciliation. Are there opportunities to bill for Med rec outside of the Transitional Care management codes 99495 and 99496?

A2: The TCM codes you mention seem to be the only fee-for-service CPT codes that specifically involve Medication reconciliation. And that is just one requirement of those codes. There is the quality measure code for 1111F for MIPS reporting that covers medication reconciliation performed within 30 days of a hospital discharge.

But when you ask about 'other opportunities' this may well have a place in the new definitions of time-based office visit codes 99202 – 99215 that will be fully in place come January 2021.

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In 2021, with the revised definition of time that includes some amount of pre- and post-visit activities, this could easily fit under the 'preparing to see the patient' or documenting clinical information in the EHR, with the Med recc time contributing to the overall time method of code selection.

Even now in 2020, were you to involve the patient in the process, this may in some circumstances count towards overall counseling time.

This month’s Coding Q&A features questions from a physician coding for time spent with hospital patients, and another wondering if there is another way to code for medical reconciliation outside of Transitional Care management codes.

Coding Q&A: Coding for time spent with hospital patients; medication reconciliation

Bill Dacey, MBA, MHA, CPC, CPC-I, answers your latest coding questions in this Q&A session.