Answers from our coding expert on questions regarding advance care planning; pessary cleaning; and identifying inclusive codes.
ADVANCE CARE PLANNING
Q: For the new Medicare advance directive planning code, does the first code for "up to 30 minutes" have to be included or "30 minutes timed counseling"?
A: What's new is that Medicare will pay for current procedural terminology (CPT) codes 99497 and 99498 in 2016. And although CPT can be somewhat inconsistent in the description of time based codes - these are pretty clear. It doesn't say "up to 30 minutes" - it says "first 30 minutes" for code 99497.
On the face of it, this would mean that 30 minutes is the minimal threshold time spent performing the indicated service in order to bill for that service. However, back in 2011 and2012, AMA added a section to the Introduction to the CPT manual that states that "a unit of time is attained when the midpoint is passed." This does not apply to all codes, but CPT usually make this clear if "less than 30 minutes" does not result in a reportable service.
This has come to be called the "CPT time convention." Although we know that Medicare does not recognize all CPT conventions, there are a couple of Medicare sources that state "Medicare recognizes this CPT guidance for many timed codes," although not specifically 99497.
Medicare does say that "Voluntary [Advanced Care Planning] means the face-to-face service between a physician (or other qualified healthcare professional) and the patient discussing advance directives, with or without completing relevant legal forms." The CPT book says that it can be with the patient, family member(s), or surrogate, but Medicare wants the patient there.
So for 99497, you need to spend between 16 minutes and 45 minutes in the planning, explanation, and discussion, and perhaps form completion, to qualify for the advance care planning code. CPT 2015 Changes states that 99498 is an extension of the work of 99397. "This service is performed when the time required to perform 99497 is greater than 45 minutes." Once you attain minute 46 - you are eligible to report code 99498 in addition to 99497.
This additional time might represent further discussion, disagreement due to family dynamics, or the competency of the adult to make his or her own decisions.
I would not advertise it as a 16-minute service to your providers - but make it clear that the minimum of 16 minutes does entitle them to the "first 30 minutes" code, or is at the very least quite defensible in this regard.
Q: What code do I use for pessary cleaning and related maintenance?
A: This is one of those cases where there is no specific CPT code that accurately describes this service. There is the 57160 code for fitting and insertion of a pessary or other intravaginal supporting device, but nothing beyond this.
Most providers will use either a 99212 or a 99213, depending on the amount of work and issues associated with the device. Remember that this can be a treatment for atrophy or various prolapses or protrusions, and that the visit, although often described as "pessary cleaning," is to some extent about assessing and treating the underlying conditions.
So there will be some history, some local examination, and in the some cases prescriptions for hormonal ointments and creams. Follow the normal guidance for the use of E&M, and if this is purely cleaning with minimal doctor involvement a 99212 will likely suffice. If underlying and multiple conditions become involved the E&M should be coded and documented at the appropriate level.
INCLUSIVE WITH OTHER CODES
Q: When do I know what codes can be billed with other codes? Or when they can't? Like different evaluation services?
A: The most specific tools to tell you what code could be considered an integral part of another code, and thereby not separately payable, are the CCI (Correct Coding Initiative) guidelines. You can find CCI on the Medicare website, and most third-party coding software contain these tables.
Medicare maintains the basic CCI guidelines, but you should know that all commercial payers make their own edits and additions to this general set of edits that affect claims processing. Every payer has their own payment policies that can directed toward their version of what codes are payable together.
The CPT manual will often tell you when one code is included in another, but it is isn't always all inclusive. Just this year in the CPT 2016, some parenthetical language was added to the preventive codes 99381-99397 that indicates that the behavior change intervention codes 99406-99409 are not included in the "counseling/anticipatory guidance/risk factor reduction interventions" portion of a preventive service. Who knew?
Since those codes were added in 2008, the language in CPT failed to indicate that the new behavior change codes could be billed separately. So how many people know that, at least as far as the AMA is concerned, you can bill a 99396 and a 99406 (smoking cessation code) at the same session?
While tables such as CCI exist, there are many combinations that you might not think to bill together, or that the language of the codes seems to steer you away from.
This year also Medicare made it clear that you can bill the advance care planning codes 99497 and 99498 along with an annual wellness visit (AWV) code G0438 or G0439. For years the AVW codes have included the "voluntary ACP, upon agreement with the patient" as an optional element of the AWV.
But per Medicare, "Effective Jan. 1, 2016, when ACP services are provided as a part of an AWV, practitioners would report CPT code 99497 (plus add-on code 99498 for each additional 30 minutes, if applicable) for the ACP services in addition to either of the AWV codes G0438 and G0439. CPT codes 99497 and 99498 used to describe ACP are separately payable under the Medicare Physician Fee Schedule (MPFS)."
This guidance goes on to state that in order to have the deductible and coinsurance waived for the ACP code when done along with an AWV, the ACP code(s) must be billed with modifier 33 to indicate it is a preventive service.
So read the fine print in both CPT, the Medicare communications, and all third-party payer documents. I would strongly suggest that every provider at least get their Medicare administrator's monthly e-mail bulletin - and read the FAQs. That's where you will find a lot of these nuggets.
Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is an AAPC-certified instructor and has been active in physician training for more than 20 years. Facing a coding conundrum? Send your questions to Dacey at email@example.com.
This article was originally published in the April 2016 issue of Physicians Practice.