New Codes for Billing Work Outside of Patient Visits
By Stephanie Farnia, ASBMT Director of Health Policy and Strategic Relations, and James Gajewski, M.D.
Evaluation & Management (E/M) coding refers to billable services from provider-patient encounters that are submitted to a patient’s insurer or payer. E/M services have been historically limited to the time during which the physician was physically in the room with the patient, discussing and taking action on any relevant concerns. Any additional care management that took place before and/or after the visit was not considered billable.
Over the last several years, physician societies from various specialties have become more vocal about finding a way to recognize the additional time it takes to manage complex patient cases outside of the in-person visit. In 2012, a coalition of specialty societies (including ASBMT) formed and proposed several care management codes to capture this extra-visit resource use. Significant work is performed outside of the patient’s clinic visits in the hematopoietic cell transplantation specialty. Examples include:
- Review of extensive medical records before an initial transplant consultation
- Coordination of care for donor and recipient care prior to transplant
- Management of care post-allogeneic transplant including planning and documenting immunosuppression, transfusion support, electrolyte replacement, infection pre-emption and treatment, hypertension and other complications of immunosuppression, comorbidity management, rehab services and other services as needed.
- Complex first outpatient visit immediately post-transplant hospitalization
- Prolonged in-person visits, especially for patients needing discussion of relapse, GVHD, chronic delirium, mental health issues and/or poor compliance
- Long-term follow-up care coordination for former patients unable to travel back to the transplant center
- End of life care and discussions with patients and family members and surrogate decisions makers
Over the past two years, many new codes were added that will now recognize much of the work done during extended patient visits or outside of the patient encounter. ASBMT’s participation on various policy committees, along with colleagues from the American College of Physicians and American Medical Association, persuaded the Centers for Medicare & Medicaid Services to recognize and value the new codes these services were assigned.
Available routine care codes:
99214 Level 4 outpatient Follow-up 1.5 relative value units (RVUs)
99215 Level 5 outpatient Follow-up 2.11 RVUs
99232 Level 2 inpatient Follow-up 1.39 RVUs
99233 Level 3 inpatient Follow-up 2 RVUs
Chronic Care Management (CCM) and Transitional Care Management (TCM) codes:
- 99354 Prolonged service face to face when an outpatient visit requires prolonged time in front of patient [>35 minutes for follow-up visit and >65 minutes for new patient] 2.33 RVUs
- 99355 Prolonged service face to face when outpatient requires even longer than 110 minutes for follow-up and 140 minutes for a new patient for each 30 min. increment 1.77 RVUs
- 99356 Prolonged service face to face when an inpatient visit requires prolonged time in front of patient [>35 minutes for follow-up visit and >65 minutes for new patient] 1.71 RVU
- 99357 Prolonged service before or after inpatient visit requiring time longer than 110 minutes for follow-up and 140 minutes for a new patient for each additional 30 min. increment 1.71 RVUs
- 99358 Prolonged service non face-to-face but associated with an outpatient or inpatient visit-when that time exceeds 35 minutes for follow-up visit and 110 minutes for new visit 2.1 RVUs
- 99359 Prolonged service non face-to-face but associated with an outpatient or inpatient visit when that time exceeds 65 minutes for follow-up when 99358 is used and 140 minutes for new visit when 99358 was used 1RVU
- 99487 Complex chronic care management-management of 2 or more diseases expected to last at least 12 months or until death with either initiation of new care plan or revision of care plan requiring supervision of 60 minutes of staff time [staff cannot be APP] 1 RVU
- 99489 Complex chronic care management-management of 2 or more diseases expected to last at least 12 months or until death with initiation of new care plan or revision of prior care plan requiring more than 60 minutes of staff time supervision for every 30 min. increment 0.5 RVU
- 99490 Chronic care management-management of 2 or more disease expected to last at least 12 months or more until death with initiation of new care plan or revision or prior care plan requiring more than 20 minutes of staff time 0.61 RVU
- 99495 Transitional care -first outpatient visit after inpatient admission as long as patient is not in skilled nursing facility or rehab hospital-when office visit is within 14 days of discharge and patient contact is documented at 2 days. Medication reconciliation is required after visit or at visit 2.11 RVUs
- 99496 Complex-first outpatient visit after inpatient admission as long as patient is not in skilled nursing facility or rehab hospital-when complexity of care requires office visit within 7 days of discharge and patient contact is documented at 2 days. Medication reconciliation is required after visit or at visit 3.05 RVUs
- 99497 Advanced care planning-for discussion of advanced directive, end of life discussions and planning with patient and family members. This can be done in addition to E/M service. First 30 minutes 1.5 RVUs
- 99498 Advance care planning for every 30 minutes beyond initial 30 minutes 1.4 RVUs
There has been quick adoption and voluminous use of the new CCM and TCM codes by many providers in the past two years. Due to this upsurge in volume, the Office of Inspector General announced in the 2017 Workplan that it will be investigating whether providers are using these codes as intended.
Because the codes often reflect a clinician’s thinking and planning time, documentation requirements are not precise. Dr. Gajewski will be participating in a meeting in late January with OIG staff to discuss these codes, why they are important to ASBMT members, and how they reflect the real professional services we provide to our complex patients. After the OIG clarifies its position on these codes, the ASBMT will create publications to better inform our members about appropriately utilizing and documenting these codes.
This article originally appeared in the Feb. 2017 issue of ASBMT eNews, p.11.