Posts Tagged ‘CPT’

Medicare’s Care Coordination Codes – New In 2013

In Uncategorized on August 23, 2013 at 5:21 pm

CMS created five new CPT codes for family/primary care physicians use in 2013. The first two will reimburse for post-discharge transitional care coordination (99495 and 99496), do not require face-to-face visits, and are anticipated to increase payments to family physicians by about 7 percent and to other primary-care providers between 3 percent and 5 percent.  The other three relate to complex care coordination, evaluation, and management (99487-99489), require direct contact with the patient, including a face-to-face visit related to the patient’s chronic care, and cover only office-based services.

While this is welcome news for primary-care physicians at face value, these new codes and two more that are proposed are leading to a place that many family practices may not want to go.

Here’s how CMS sets things up: The agency says it has recently “recognized primary care and care coordination as critical components in achieving better care…” and wants to “encourage long-term investment in primary care and care-management services” through “accurate payment.”

The agency also contends that it will continue “…to hear concerns from the physician community…” Such voiced concerns include the following:

  • Since only primary care is eligible for reimbursement, the entire responsibility for coordinating care falls on primary-care practices, many of which will have to invest further in people, procedures, and systems to manage it.
  • Focusing on processes such as care coordination and transition only better manages the process.
  • Rewarding process improvement is a step forward in efficiency, but a step away from a solution — such as also investing in physicians to engage, educate and equip patients to do their part to succeed in the treatment and prevention of chronic conditions in ways that they can understand.

CMS sort of addresses the latter of the concerns by offering up something under the auspices of the ACA: an HCPCS G-code that specifically pays for “post-discharge transitional care management services.”  In the agency’s words, the proposed code will pay for “all non-face-to-face services related to the transitional care management … within 30 calendar days following the date of discharge from an inpatient acute-care hospital, psychiatric hospital, long-term care hospital, skilled nursing facility, and inpatient rehabilitation facility; hospital outpatient for observation services or partial hospitalization services; and a partial hospitalization program at a community mental health center to community-based care.”

Of the 11 primary tasks on the punch list for this new code, four recognize that there is an actual patient involved, and represent the bulk of the work required to qualify:

  1. Establishing a personalized plan of care with the patient;
  2. Being sure the patient or caregiver understands their medications;
  3. Educating the patient or caregiver about the home care plan, potential complications, and what to do if they happen; and
  4. Helping the patient or caregiver to determine and establish any needed home services and community-based resources.

The American Academy of Family Physicians estimates that payment for two new codes (99495 and 99496) would be about $94.62.  CMS is estimating the codes would apply to about 10 million discharges in 2013.  Since this proposal is subject to budget neutrality policies, it would move about $95 million annually from other services to primary care.  That would be taking money from those that primary care is coordinating with. That helps to seal the deal that the plan may well be for primary care to own care coordination and transition exclusively.

So what may have appeared to be a windfall may prove to be much less so in practice.


Coding Clarification – 99000 Mis- and Over-Use

In Uncategorized on August 22, 2013 at 6:32 pm

Upon a recent audit of provider claims, MEDIC, Inc. identified an apparent overuse of 99000.  As such, M.E.D.I.C., Inc. feels that there is a general need to clarify the use of CPT code 99000.  This code should NOT be used when a blood sample is drawn at the office and sent out to the lab.  Rather the 99000 should be used if a specimen is collected (for example cultures of wounds, urine, C&S) for a lab test done at an out lab.

When reviewing revenue detail reports related to the 99000, it is evident that few 99000 claims are actually paid, and those that were were classified as self pay (i.e., they were patient responsibility, not billed to insurance).

Additionally, this code is not billed as a stand-alone code—it is always with an office visit – and when the 99000 is charged with an office visit, rarely if ever does one see a payment.  Per the CCI edits, it is deemed inclusive to the office visit.  In fact, Medicare does not even include the 99000 on their fee schedule.

You can certainly continue to use this code, but most carriers are going to follow the CCI edits and refuse to pay it, and you will not have any basis for appeal.  It is inapproptiate to merely attach the -25 modifier.  Essentially, this code is used primarily for reporting purposes rather than reimbursement.

Please see the following comments addressing the 99000 as well:

  • AMA Comment:  The codes listed in the special services, procedures and reports section (99000-99091) identify various services and reports that are adjunctive to the basic services rendered. These codes describe circumstances under which practitioner services are performed.

Modifier -25 indicates that a separately identifiable E/M service was performed on the same day as another independent procedure or service by the same physician. When a code from the special services, procedures and reports section is reported with an E/M service, modifier -25 should not be appended to the E/M service, as the codes from the 99000-99091 series do not describe separately identifiable services, but rather adjunctive services or circumstances that further describe the basic service rendered.

  • From the AAFP Website:  Most people use 99000 incorrectly. It is not used for obtaining a specimen.  CPT code 99000, “Handling and/or conveyance of specimen for transfer from the physician’s office to a laboratory,” is intended to be reported when the practice incurs costs to handle and/or transport a specimen to a lab. For example, if the practice employs a messenger service to transport a specimen, that service can be coded using 99000. In contrast, if lab staff pick up a specimen at no additional cost to the practice, it would not be appropriate to report code 99000. 

Finally, 99000 is not intended for reporting the obtaining of a specimen.  Reimbursement for obtaining a Pap smear or a throat culture is factored into the relevant lab procedure code.  Obtaining a blood specimen by venipuncture may be reported separately, using code 36415, “Routine venipuncture or finger/heel/ear stick for collection of specimen(s).”  However, 99000 may be used to reflect the work involved in the preparation of a specimen prior to sending it to the laboratory (e.g., centrifuging a specimen, separating serum, labeling tubes, etc.).  For in-office tests, you should submit only the appropriate code for the test itself.  Note that Medicare and many other payers consider code 99000 to be a bundled service that is not separately payable.