The Most Significant Update to the 2017 CPT Manual

January 31, 2017

This month's coding column is on the biggest change to the 2017 CPT manual and billing related to depression and alcohol misuse screening.

Q:  What is the most significant addition or update to the 2017 CPT manual? We hear so much about so many changes.

A: If there were to be one most important or significant change it would surely depend on your specialty. Even one small change in one code could alter a practice dramatically if that was your principle service.

However, the most profound change is likely the elimination of the bullseye symbol throughout the manual. This means that 441 codes that used to include conscious sedation no longer do.

Several new conscious sedation codes were added to report in addition to the surgical code when the surgeon also provides the sedation. This has an effect on endoscopies principally, but cover many diagnostic and therapeutic scope procedures.

Q: We have several providers billing G0444 and G0442, depression and alcohol misuse screening respectively. Medicare has requested some notes and have now denied 15 of them due to lack of time documented.  I know it states several minutes but is this one of those codes that you can report it as long as you do eight minutes?

A: Medicare has several publications related to these codes, but they principally dwell on medical necessity and documentation of the various instruments or tools used in depression screening. They really don't talk much about these codes and the time requirement.

Recently Medicare cited the 'midpoint rule' (once you have achieved over half of the specified time you qualify for the code) for the newer advanced care planning codes, 99497 and 99498, but we've not seen them specifically linked to these codes. Remember that each Medicare Administrative contractor (MAC) can apply their own guideline to these codes.

The code descriptions do universally state '15 minutes,' not 'up to 15 mins.' That said we have heard anecdotally that some state MACs have instructed providers that they read this as 'up to' 15 minutes. However, if your Medicare entity is denying based on documented time, you can certainly find out if the 'midpoint rule' is in effect. If they say you aren't meeting the standard, find out what the standard is.

Many doctors don't do time on these. I would certainly go for the midpoint approach, but if there is no documentation of time at all, then you likely owe them the money.

Q: I work in a valve clinic. When I do a one-week wound check should I be doing a review of systems (ROS) and a physical exam?  I am examining the wound site, but not typically doing a full or partial exam of the rest of the body.  I do listen for a murmur, which should have resolved as a result of the surgery, but that is it.

A: When you do wound checks, if they are out of the global, you are probably only doing a 99212 or 99213 level visit. The most ROS that the 99213 requires is one. Also be sure that you ask at least one question: integumentary or constitutional?  And be sure to document that example.

Likewise with the exam - a 99212 requires only one system (skin or constitutional, for example) and a 99213 requires two systems. So if you did constitutional (ill appearing, well appearing, etc.), skin and listened for a murmur you'd easily meet that requirement. The decision-making piece will depend more on the scope of the visit - is it truly a wound check or does this follow up visit address the initial valve problem?