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Complex Care Coordination; Counseling Code Confusion


Answers from our coding expert on questions regarding discharge code requirements; complex care coordination; and counseling code confusion.


Q: I am a hospitalist. I had a situation last week where a patient left before I could see him, but I did do all the discharge paperwork and coordination. This took me some time that day. Can I bill the discharge code?

A: The CPT manual reads that the work of the discharge codes includes, as appropriate: final examination of the patient; discussion of the hospital stay, even if the time spent by the physician on that date is not continuous; instructions for continuing care to all relevant caregivers; and preparation of discharge records, prescriptions, and referral forms.

Medicare would very likely take the position that without a face-to-face visit, no "encounter" took place so it could not be billed. So, although you did work on the patient's behalf, and in these circumstances the non-face-to-face work is the larger portion of the collective work, no visit service should be billed without a patient visit.


Q: When do you bill the new complex care coordination codes, and what exactly do I have to have in place to use them? I heard that I need special forms.

A: The code you are probably interested in is CPT code 99490 that CMS has selected from among the 2015 CPT codes as its payable complex care management service (CCM).

An extensive list of requirements is associated with these codes but these requirements should not be that difficult for most practices to meet. If you meet all the conditions, you can bill the code on the first day of the next month following the month when you provided the services. In this regard these codes work much like the care plan oversight codes that have been around for many years.

As to forms, the provider must obtain the beneficiary's written consent to provide CCM services. The beneficiary must acknowledge in writing that the provider has explained the following items:

1. The nature of CCM.

2. How CCM may be accessed by the patient and provider.

3. That only one provider at a time can furnish CCM for the beneficiary.

4. That the beneficiary's health information will be shared with other providers for care-coordination purposes.

5. That the beneficiary may stop CCM at any time by revoking consent, effective at end of the then-current calendar month.

6. That the beneficiary will be responsible for any associated copayment or deductible.

You will also need a specific location within your EHR to house the actual care plan. The five itemized requirements for providing this service are:

1. Use a certified EHR for specified purposes.

2. Maintain an electronic care plan.

3. Ensure beneficiary access to care.

4. Facilitate transitions of care.

5. Coordinate care.

Do go to the Medicare website for more detail on the CCM requirements.


Q: I am an interventional cardiologist, however, every day I feel more passionate about prevention. Even though I tend to spend a lot of time counseling and talking about obesity, diet, nutrition, exercise, diabetes, etc., I find it hard to get reimbursed for that. I am even in the process of hiring a dietitian/nutritionist, but I am not completely clear regarding the rules to bill for her services. When I look at the CPT code book, there seem to be multiple possible codes. Which ones should I use? How much will I be reimbursed?

A: There is no actual obstacle to your using the standard office visit codes 99201 to 99215 for counseling services, especially as they pertain to cardiovascular disease. I am assuming that patients don't come to you solely for the purposes of prevention, and that their encounters with you indicate some type of condition or suspected condition. In these circumstances, you can bill with the diagnosis code of the problem, and code the CPT visit code based on time counseling, as long as there is a clear link to the diagnosis, the content of the counseling, and the time spent. You can even use prolonged services here, if need be. So, I am a bit unsure what the "I find it hard to get reimbursed for that" comment is based on.

Your question broadens a bit when you discuss hiring a dietician/nutritionist, as that would allow use of the nutrition counseling codes. Several of the counseling type codes are not designed for physicians but for other licensed professionals. If you are doing the work, I would recommend the basic office visit codes listed above or even consultation codes if the circumstance and payer allows that. For other provider types, look into the CPT assistant articles by the AMA for greater detail and the Medicare website for specific code coverage requirements.


Q: I'm not sure how to bill for some of our hospitalist group services. Can you provide some guidance on the following scenario?

A patient was admitted on Nov. 17 and discharged on Nov. 18. The patient went home and was readmitted the next day.

We have an admission history and physical on Nov. 17 and a discharge summary on Nov. 18. Another provider from our group did a progress note on Nov. 19, when the patient was readmitted.

Is this correct? Or should we have another admission history and physical for Nov. 19? Some of the confusion is because the patient was readmitted in less than 24 hours.

Should the billing be: Nov. 17, 99223; Nov. 18, 99239; Nov. 19, 99220?

A: You have the coding correct assuming that the second admit ended up being an observation admission, and also met documentation requirements for those codes. This also assumes that your levels were correct.

Physicians aren't really governed by the old "24-hour" rule - that is for hospitals and the facility side of billing. Professional services are based on calendar date. Since the patient was discharged on one day, and readmitted the next, each day is represented by its respective code.

To qualify for an observation admit for Medicare, the patient must be in-house for at least eight hours, but otherwise you really don't have any timing issues here.

Of some concern is the comment that the second admit was represented by a "progress note" versus an admission, history, and physical. If this is the case, and the note only supports a follow-up type visit versus an admit-style note, then you may have to bill either 99231 to 99233 or 99224 to 99226.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years.

This article originally appeared in the March 2015 issue of Physicians Practice.

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