By Jacqueline Nash Bloink, MBA, CPC-I, CHC
There are three types of wellness visits, each of which has different requirements. To know if you are being compliant with requirements and coding correctly, know what each entails:
1. Initial Preventive Physical Examination (IPPE) or the “welcome to Medicare preventive visit” – use code G0402 Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment to describe this service. The beneficiary can only receive this visit during the first year that he or she is eligible and enrolled in Medicare. If the patient does not exercise his or her right to request this visit during that first year, he or she will never again have the chance to request it.
During this visit, the beneficiary is eligible for a screening electrocardiogram (EKG) (G0403-G0405) and aortic aneurysm ultrasound (AAU), if he or she meets the following requirements:
- Patients may be eligible for the screening EKG if a referral is given during the welcome to Medicare preventive visit (G0402) or the EKG is performed during this visit.
- AAU is provided as a one-time screening if the beneficiary gets a referral as a result of the welcome to Medicare preventive visit (G0402), has never had an AAU under the Medicare program, and meets certain eligibility requirements. An eligible patient is one who: (1) has a family history of abdominal aortic aneurysm, or (2) is a male, aged 65-75, who has smoked at least 100 cigarettes during his lifetime, or (3) has other risk factors recommended for ultrasound screening as specified by the national coverage determination process.
For more detail on the EKG and AAU screenings, visit the CMS website.
2. Initial Medicare Annual Wellness Visit (AWV) – After 11 full months have passed, the beneficiary is eligible for the next preventive visit, initial “annual wellness visit.” Use code G0438 Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit to report this. This visit can be performed at any point in the beneficiary’s life, but only once during his or her lifetime. This code was implemented by CMS in 2011.
3. Subsequent AWV – After 11 full months have passed since the initial wellness visit, the beneficiary is eligible for the “subsequent wellness visit” described by code G0439 Annual wellness visit, includes a personalized prevention plan of service (PPS), subsequent visit. A beneficiary can request this visit every year (after 11 full months have passed between visits), if so desired.
You can find a summary of the requirements of all Medicare wellness visits on the CMS website.
December 14th, 2012
By Jacqueline Nash Bloink, MBA, CPC-I, CHC
The Centers for Medicare & Medicaid Services (CMS) has begun a campaign to educate Medicare beneficiaries about preventive services, including wellness visits, available to them. There is even a YouTube clip to promote these visits. If CMS believes these visits are such a great service for the beneficiary, why do so many physicians cringe when they hear an appointment has been scheduled for such a service?
Manage Patient Expectations
Beneficiaries often expect a head to toe examination during the wellness visit, but this is not what it delivers. Office staff must begin to educate the beneficiary that the wellness visit is a plan of care. When the beneficiary understands the wellness visit was created to take a snap shot of his or her current health status, and the physician won’t be performing a physical examination, the situation will be better controlled—meaning fewer angry beneficiaries and more physicians willing to perform the service.
Staff should also inform beneficiaries they will not incur a co-pay for a wellness visit, but if another service is provided during the visit, there will be a co-pay for that portion of the visit.
CMS has many educational resources available to physician offices to assist with explaining wellness visits to patients, including a downloadable patient brochure.
Three Visit Types, Three Sets of Requirements
There are three types of wellness visits, each of which has different requirements.
1. G0402 Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment describes the “welcome to Medicare preventive visit.” The beneficiary can only receive this visit during the first year that he or she is eligible and enrolled in Medicare. If the patient does not exercise his or her right to request this visit during that first year, he or she will never again have the chance to request it.
During this visit, the beneficiary is eligible for a screening electrocardiograph (EKG) (G0403-G0405) and aortic aneurism ultrasound (AAU), if he or she meets the following requirements:
- Patients may be eligible for the screening EKG if a referral is given during the welcome to Medicare preventive visit (G0402).
- AAU is provided as a one-time screening if the beneficiary gets a referral as a result of the welcome to Medicare preventive visit (G0402). Eligible patients are those who either have a family history of abdominal aortic aneurysm or if the patient is male, aged 65-75, who has smoked at least 100 cigarettes during his lifetime, and the patient has never had an AAU paid for by Medicare during his or her lifetime.
For more detail on the EKG and AAU screenings, visit the CMS website: www.medicare.gov/navigation/manage-your-health/preventive-services/preventive-service-overview.aspx).
2. After 11 full months have passed, the beneficiary is eligible for the next wellness visit. G0438 Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit describes the “initial Medicare wellness visit.” This visit can be performed at any point in the beneficiary’s life, but only once during his or her lifetime. This code was implemented by CMS in 2011.
3. After 11 full months have passed since the initial wellness visit, the beneficiary is eligible for the “subsequent” wellness visit (G0439 Annual wellness visit, includes a personalized prevention plan of service (PPS), subsequent visit). A beneficiary can request this visit every year (after 11 full months have passed between visits), if so desired.
You can find a summary of the requirements of all Medicare wellness visits on the CMS website.
Create a Template to Make Documentation Easy
If the physician’s office combined all of the components of each of the three visits together to create one master template, as shown in Example A, the beneficiary would get a few extra benefits each year, while making things easier for the physician.
Items in red represent the services the physician provided during the visit that may have not been needed during that particular visit, but were required in one of the other visits. If all 10 steps are performed during the G0402, G0439, or G0438 visit, the provider does need to stop and think which component he or she is missing, making life much easier for both physician and patient.
By following a template for documenting wellness visits, the staff becomes familiar with the steps, and patients become accustomed to the questions and are prepared to answer them each year.
The health care team at the office (medical assistant, licensed practical nurse, or registered nurse) may be able to assist the health care professional (nurse practitioner or physician assistant) in obtaining 75 percent of the information prior to the physician entering the room to talk with the patient. Each year, the physician will have a written description of the beneficiary’s lifestyle and will be better prepared to address various risks that the patient may face as he or she ages.
With the wellness visit well-documented, all that remains is scheduling next year’s wellness visit (remember: at least 11 full months after this visit).
Example A:
10 Easy Steps to Document Medicare Wellness Visits
1. Patient completes the required “Health Risk Assessment Questionnaire” prior to the visit with the physician (this is new for 2012). Guidelines for creating a form with all of the necessary components can be found at the Centers for Disease Control and Prevention (CDC) website.
2. Office staff documents the patient’s height, weight, blood pressure, body mass index (BMI), and visual acuity.
3. Patient’s medical history, family history, and social history are discussed and documented. Special attention is paid to past illnesses, surgeries, allergies, and injuries. Family history is pertinent with hopes of catching high-risk areas that may be modifiable or identified with special screening tools. The social history will be helpful in documentation of substance abuse such as smoking or alcohol.
4. Patient is queried about current or past events of depression. Make sure to list the type of depression tool used to determine the risk. Examples of such tools might include PQ1, PQ2, or Zing.
5. List all current medications, including vitamin supplements.
6. List all current providers and suppliers that the patient is seeing (specialists, diabetic suppliers, etc.).
7. Assessment of functional ability and safety: This must include:
- Hearing
- Daily living activities
- Risk of falling
- Safety/home life/risks
8. Cognitive impairment assessment and observation. Information may also be obtained from the patient’s family, caregivers, or friends.
9. End-of-life planning and advance directives. Does the physician agree with this plan?
10. Written plan of preventive services that the patient is eligible for the next one to 10 years. The patient takes this plan when he or she leaves the office.
Jacqueline Nash Bloink, MBA, CPC-I, CHC, lives in Tucson, Ariz. and is director of compliance for Arizona Community Physicians.
August 1st, 2012
By Nancy Clark, CPC, CPC-I
Modifiers are crucial in telling the story of the claim by identifying procedures that have been altered in some way without changing the core meaning of the code(s) submitted. Let’s look at the modifiers that can be appended to evaluation and management (E/M) codes used within the global period.
The Global Surgical Package
Understanding global modifiers begins with a comprehension of the global surgical package. The CPT® surgical package definition indicates that for every surgical procedure, there are integral services included that cannot be reported or billed separately, as indicated in Example A.
The Centers for Medicare & Medicaid Services (CMS) refers to the surgical package concept as the “global period.” In minor procedures, such as removal of skin lesions or endoscopies, a zero- to 10-day global period after the procedure applies. For major surgeries, the global period is extended to one day prior to and 90 days after the procedure. An example of a major surgery would be an appendectomy. Note that commercial carriers may place different global periods on procedure codes.
One way to determine the global period for Medicare is by using the Medicare Physician Fee Schedule Database (MPFSDB). Global surgery status indicators are attached to each procedure code from the surgery section of CPT®, as shown in Example B.
Modifiers 24, 25, and 57 (see descriptors below) can be appended to E/M codes, which include CPT® 99201-99499, and ophthalmology codes 92002-92014; the latter codes are found in the medicine section of CPT®.
Modifier 24
Modifier 24 Unrelated evaluation and management service by the same physician during a postoperative period shows the E/M being billed is not part of the global surgical package and is separately reimbursable. To further indicate the procedure is unrelated, we usually—although not necessarily—use a different diagnosis from that linked to the previous procedure.
For example, on May 1, the patient undergoes an appendectomy for acute appendicitis. The appropriate coding based on this information is 44950 Appendectomy with 540.9 Acute appendicitis; without mention of peritonitis. On May 19, the patient presents to the same operating surgeon with a new onset of right upper quadrant (RUQ) abdominal pain. At this visit, the surgeon examines the patient and suspects cholecystitis. He orders a complete blood count (CBC) and abdominal ultrasound, and documents an expanded problem-focused history, expanded problem-focused exam, and medical decision-making of low complexity.
The appropriate coding on May 19 is 99213-24 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity … with a diagnosis of 789.01 Abdominal pain; right upper quadrant. Modifier 24 is appended to indicate that this E/M is unrelated to the previous surgery. Notice the use of different diagnoses.
In this next example, it is appropriate for the same diagnosis to be used for both the surgery and the subsequent E/M service: On June 1, the patient presents for a closed treatment of a single metacarpal fracture in his left hand. The appropriate coding is 26600-LT Closed treatment of metacarpal fracture, single; without manipulation, each bone, which has a 90-day global period. Modifier LT Left side is appended to indicate location. The diagnosis is 815.03 Fracture of metacarpal bone(s); closed; shaft of metacarpal bones(s).
On July 1, the patient presents to the same operating surgeon, complaining of a possible fracture in his right hand. The physician performs an expanded problem-focused history and exam and his medical decision-making is of low complexity. After review of the X-rays, which may be separately billable, the physician identifies a new metacarpal shaft fracture. The appropriate coding is 99213-24, with 815.03. Note the use of the same diagnosis. Modifier RT Right side for the right hand would not be appropriate for the E/M code.
Modifier 25
Append modifier 25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service to indicate that an E/M service is separate from what is normally required for a minor procedure. There must be a clearly documented, distinct, and significantly identifiable E/M service, above and beyond the usual preoperative and postoperative care associated with the procedure. The CPT® description of modifier 25 specifies, “The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M service on the same date.”
For example, an established patient presents to the office complaining of left eye pain and feeling as if sand is in his eye after doing some repair work around his house. The physician performs an examination, finds a wood splinter in the cornea, and removes it. He documents a problem-focused history and exam and straightforward medical decision-making. The appropriate coding is 99212-25 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making … and 65220-LT Removal of foreign body, external eye; corneal, without slit lamp with 930.0 Corneal foreign body.
Alternatively, for an eye examination, report 92012-25 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient and 65220-LT.
Modifier 25 for Combo Sick/Well Visits
Modifier 25 also may be used when a preventive service (well visit) and a problem-oriented E/M (“sick visit”) occur during the same encounter. CMS instructs, “Medicare payment can be made for a significant, separately identifiable medically necessary E/M service (Current Procedural Terminology codes 99201-99215) billed at the same visit as the Annual Wellness Visit (AWV) when billed with modifier -25. That portion of the visit must be medically necessary to treat the beneficiary’s illness or injury, or to improve the functioning of a malformed body member.” (https://questions.cms.gov/)
In this instance, be sure the documentation can substantiate two distinct E/M codes. One visit would be measured by the key components of history, examination, and medical decision-making (or, possibly the time component). The other service needs to indicate a full preventive care service. The modifier is appended to CPT® problem-based codes. Keep in mind that commercial payers’ policies vary. Some will not pay for two E/Ms on one date of service and some payers may reduce the amount of the second E/M reimbursement. It is important to check with the payer to verify both the coding policy and the patient’s benefits.
For example, a 35-year-old established patient had previously scheduled an appointment for a routine examination. On the day of the appointment she injures her ankle. The documentation of the visit supports a problem-focused history related to the ankle injury, a problem-focused examination of the ankle, and medical decision-making of straightforward complexity. The documentation also separately supports a comprehensive preventive medicine E/M service.
The appropriate coding of this service for a commercial payer is 99212-25, with a diagnosis of 845.00 Sprains and strains of ankle; unspecified site. You would also report 99395 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years with a diagnosis of V70.0 Routine general medical examination at a health care facility.
For Medicare, there are several options for reporting the wellness exams:
- For a Medicare Initial Preventive Physical Exam (IPPE), use HCPCS Level II code G0402 Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment.
- For a Medicare AWV, use HCPCS Level II code G0438 Annual well visit; includes a personalized prevention plan of service (PPS), initial visit for a new patient or G0439 Annual well visit; includes a personalized prevention plan of service (PPS), subsequent visit for an established patient.
For clarification of the Medicare IPPE and AWV guidelines, see the Medicare Claims Processing Manual chapter 12, 30.6.1.1, “Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV).”
Whether reporting to commercial payers or Medicare, the use of different diagnoses for sick and well visits further differentiates the services.
Modifier 57
Modifier 57 Decision for surgery is similar to modifier 25, except that the surgical package includes one day prior to the procedure and usually has a 90-day global period after the procedure. Note: The CPT® description of the modifier does not actually indicate a global period, but most payers’ guidelines indicate use for a major global period. The E/M may be for the same or for a different diagnosis than the surgery.
Remember CPT® surgical package guidelines include one related E/M encounter subsequent to the decision for surgery. So, if the operating physician performs an E/M on the day before a previously scheduled surgery that includes normal preoperative care for the surgery, the E/M is not separately reportable because it is included in the global package. If the operating physician sees the patient the day before the surgery and at that visit decides to perform surgery, however, modifier 57 can be properly appended to indicate the E/M is not “bundled” into the surgery because a decision for surgery was made at this visit.
For example, a non-Medicare patient presents to the emergency department (ED) with acute right, lower-quadrant abdominal pain and fever. The ED physician requests a surgical consult. The consulting surgeon documents a level 3 outpatient consult and decides at that visit to perform an emergency appendectomy.
The appropriate coding is 99243-57 Office consultation for a new or established patient … , 44950, and 540.9.
Note: The global period of the performed procedure determines whether it is appropriate to append modifier 25 or modifier 57 to the E/M code.
Nancy Clark, CPC, CPC-I, is a member of the 2011-2013 AAPC National Advisory Board (NAB). She is director of the Healthcare Business Resource Center in New Jersey. She also She also is a PMCC-approved instructor and a health care consultant. Ms. Clark participates in the Novitas Medicare Provider Outreach and Education Advisory Group.
Whether it’s new modifiers, E/M, radiology, or Category II codes, we have the outlook for what’s on the horizon.
By Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC
CPT® 2012 arrives with over 500 code changes, plus minor additions to the Evaluation and Management Services Guidelines.
The revised evaluation and management (E/M) guidelines clarify the “three-year rule” for new versus established patients, stressing “A new patient … has not received any professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years” [emphasis added]. In this context, CPT® 2012 defines “professional services” to mean any face-to-face service “rendered by a physician and reported by a specific CPT® code(s).”
To help determine a patient’s status easily, CPT 2012® re-establishes the “Decision Tree for New vs. Established Patient” that was included in CPT® 2010, but left out in 2011.
Modifiers
The “Instructions for Use of the CPT Codebook” are unchanged, as are the Anesthesia, Surgery, and Medicine sections guidelines. Appendix A adds two modifiers not found on the inside front cover of the book, however.
Modifier 33 Preventive services has been effective since Jan. 1, 2011, but appears in CPT® for the first time. Append this modifier when reporting preventive services delivered “in accordance with a US Preventive Services Task Force A or B rating in effect” and “other preventive services identified in [legislative or regulatory] preventive services mandates.” Examples include the Medicare initial preventive physical exam (G0402) and annual wellness visits (G0438 and G0439).
Do not apply modifier 33 for separately reported services specifically identified as preventive (such as screening mammography, 77057; screening colonoscopy, G0105 or G0121; or prostate screening with PSA, G0103). If the physician converts a screening colonoscopy to a diagnostic colonoscopy (e.g., 45385), you should instead append modifier PT Colorectal screening test converted to diagnostic test or other procedure to the diagnostic colonoscopy code to indicate the procedure began as a preventive service.
Append modifier 92 Alternative laboratory platform testing when:
- A laboratory test is performed using a kit or transportable instrument that wholly or in part consists of a single use, disposable, analytical chamber;
- the test does not require permanent dedicated space; and,
- the test is designed to be carried or transported to the vicinity of the patient for immediate testing at that site.
For Medicare payers, modifier 92 indicates point-of-service HIV testing (86701-86703 and 87389) only. Per Centers for Medicare & Medicaid Services (CMS) transmittal 2277, modifier 92 is effective Oct. 1, 2011 for this purpose. Modifier 92 was introduced in CPT® 2008, and Medicare will allow you to apply the modifier retroactively to claims filed on or since Jan. 1, 2008.
CPT® 2012 re-establishes the “Decision Tree for New vs. Established Patient” that was included in CPT® 2010, but left out in 2011.
Category I Changes
The majority of changes to CPT 2012® involve Category I codes, to include over 200 new codes, more than 180 deleted codes, and more than 130 revisions. Only the Anesthesia (00100-01999) and Surgery: Urinary System (50010-53899) portions of CPT® were untouched this year.
Evaluation and Management
E/M changes include the addition of “reference times” to Initial Observation Care codes 99218, 99219, and 99220. For example, the descriptor for 99220 now specifies, “Physicians typically spend 70 minutes at the bedside and on the patient’s hospital floor or unit.” The new language allows physicians to report the initial observation care codes using time as the key component, when counseling or coordination of care dominates the encounter.
Prolonged Services codes 99354-99355 (office or outpatient) and 99356-99357 (inpatient or observation) gain instructions stating these codes may be used by physicians or other qualified health care professionals. These add-on services specifically include total face-to-face time with the patient, as well as non face-to-face services on the patient’s floor or hospital/nursing facility unit during the same session. The time does not have to be continuous, but only a single prolonged service code may be reported per day.
Prolonged services without direct patient contact (99358-99359) also gain guidelines, clarifying that these add-on services may be provided on a different date than the related, primary service (which must have been face-to-face, but need not have a reference time).
Added guidelines now precede the Inpatient Neonatal and Pediatric Critical Care (99468-99476) and Initial and Continuing Intensive Care Services (99477-99480) codes to define more precisely the services included and how the codes are applied.
Integumentary
The big news in the Integumentary section is a near complete overhaul of the skin replacement/skin substitute codes. Many codes in the 15300-15431 range have been deleted, replaced by fewer (and much simplified) codes, such as 15271 Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area and +15272 … each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure). The replacement codes (15271-+15278) do not include supply of the graft, which may be reported separately.
Add-on code 15777 Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (eg, breast, trunk) (List separately in addition to code for primary procedure) has been established to describe biologic implant for soft tissue reinforcement. Many other integumentary code descriptors include minor revisions.
Musculoskeletal
Changes to musculoskeletal codes involve mainly descriptor revisions, either to clarify the intent of the service or to describe bundled services. For example, descriptors for percutaneous vertebroplasty (22520-22522) specifically identify bone biopsy as an included service when performed. A number of injection procedures (e.g., 27096 Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed)) now clearly include image guidance.
Two new codes (22633 and 22634) describe arthrodesis via combined posterior and posterolateral technique with posterior interbody technique.
Respiratory System
Codes describing thoracotomy and other procedures of the lung and pleura undergo significant changes, to include nearly a full page of new instructions and added parenthetical notes. Every “removal of lung” code (32440-32491) has been revised. There are six new codes for thoracotomy (32096-32098, with biopsy; and 32505-+32507, with wedge resection), and an entirely new category (32601-32674) has been established for video-assisted thoracic surgery (VATS), which includes a dozen new codes.
Cardiovascular
Pacemaker or Pacing Cardioverter-Defibrillator codes (33202-33249) have undergone frequent revisions in the past few years, and 2012 is no exception. There’s an additional page of instructions for code application, as well as a quick reference chart to help with code selection for the insertion, removal, etc. of a pulse generator and its various components. Over a dozen codes in this section have been revised, with nine codes added.
Combination codes were added to report renal catheterization and angiography (36251-36254). The new codes include the radiological supervision and interpretation.
Added instructions clarify that replacement of ventricular assist device pump (33981-33983) includes removal of the new pump, as well as connection, de-airing, and initiation of the new pump.
Digestive
There are relatively few changes to this section of CPT®. Several parenthetical notes have been added to clarify code selection. For instance, a note added to the Stomach: Laparoscopy codes (43644-43659) instructs, “For laparoscopic implantation, revision or removal of gastric neurostimulator electrodes, lesser curvature [morbid obesity], use 43659.” Three new codes (49082-49084) describing abdominal paracentesis replace deleted codes 49080 and 49081. Liver biopsy (47000) now includes moderate sedation, when provided.
Genital Systems
There are no changes in the Surgery/Male Genital System portion of CPT®. The Surgery/Female Genital System codes also are unchanged, but several parenthetical notes have been added throughout the section. Among these is instruction to report 11981 for insertion of a non-biodegradable contraception implant, and 11976-11981 for removal with subsequent insertion.
Nervous System
Codes 64622-64627 have been deleted, replaced by 64633-64636 for destruction of paravertebral facet joint by neurolytic agent. The new codes specify location (cervical or thoracic and lumbar or sacral) and the number of joints injected (single and each additional). Many additional code descriptors have undergone revision to better specify the intent or application of the code. For example, the term “array” was added to implantation of neurostimulator code (64553-64565 and 64575-64585) descriptors to clarify that the codes are applied per array, not per individual electrode (an array may contain several electrodes). New parenthetical notes and instructions appear throughout the section.
Eye/Ocular Adnexa and Auditory System
These sections include only minor changes, including new parenthetical instructions (e.g., “For fitting of contact lens for treatment of disease, see 92071, 92072”) and the deletion of 69802 Labyrinthotomy, with perfusion of vestibuloactive drug(s); with mastoidectomy.
Radiology
Of the many changes to the Radiology section, the most significant include the creation of new codes to report intra-operative radiation treatment delivery (77424, 77425) and intra-operative radiation treatment management (77469). New instructions specify that radiation treatment management is reported in units of five fractions or treatment sessions, regardless of the actual time period in which the services are furnished.
Atherectomy codes 75992-75996 have been deleted and replaced with other codes. For instance, in 2012, in place of 75995, use Category III code 0235T Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; visceral artery (except renal), each vessel.
Path and Lab
CPT® 2012 establishes an entirely new section for molecular pathology, including two full pages of instruction and dozens of new codes for Tier 1 (81200-81383) and Tier 2 (81400-81408) molecular pathology procedures. Molecular pathology procedures involve analyses of nucleic acid to detect variants in genes that may be indicative of germline or somatic conditions, or to test for histocompatibility antigens. Code selection is based on the specific gene analyzed.
Parenthetical notes now accompany HIV-1 and HIV-2 testing code 86703 (single result) to clarify proper coding for alternative testing, such as HIV-1 antigens(s) with HIV-1 and HIV-2 antibodies (87389), and when to apply modifier 92 with 86701-86703 and 87389.
Medicine
Descriptor revisions clarify immunization coding (90460, +90461) by vaccine component, rather than per injection. Esophageal motility studies will no longer be reported with 91011 or 91012; instead, you will use revised codes 91010 (for motility study) and +91013 (an add-on code for stimulation or perfusion). Code 92070 is deleted and replaced by two new codes (92071 and 92072) for contact lens fitting to treat ocular surface disease or to manage keratoconus, respectively.
A full page of instructions has been added for sleep medicine testing, and new codes have been added to report needle electromyography, per extremity (95885, limited; and 95886, complete) or non extremity (95887). Hydration codes (96360 and +93631) also come with significant additional instructions in 2012, to better explain the meaning of “initial infusion,” “sequential infusion,” and “concurrent infusion.”
Good weather, a good friend, and a good codebook—what more does a girl need?
Category III Codes
Over 30 new Category III codes have been added to CPT® 2012, including those for intramuscular autologous bone marrow cell therapy (0263T-0265T), percutaneous laminotomy/laminectomy (0274T, 0275T), corneal incision (0289T, 0290T), and more. Category III codes describe emerging technologies and, unlike Category I “unlisted procedure” codes, allow for tracking and collection of specific data. If a Category III code is available, it must be reported instead of a Category I unlisted procedure code.
Look for more: We’ll be covering specific information on individual CPT® code changes in upcoming issues of Coding Edge.
Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC, is AAPC director of education, and a member of the CPT® Health Care Professionals Advisory Committee (HCPAC).
December 1st, 2011
Understand the Medicare Primary Care Center Exception.
By Maryann C. Palmeter, CPC, CENTC
The final rule for teaching physician presence and documentation requirements under Medicare Part B has been in effect since July 1, 1996. Over the years, the Centers for Medicare & Medicaid Services (CMS) has issued changes and clarifications to the rule. Most recently, CMS authorized the addition of new annual wellness visit codes G0438 and G0439 to the list of services that can be performed under the “Primary Care Center Exception” (refer to CMS Transmittal 2303, Change Request (CR) 7378, dated Sept. 14, 2011).
CMS also added specific manual language (Medicare Claims Processing Manual, Pub. 100-04, chapter 12, sections 100.1 and 100.1.1 (C)) to clarify how the Primary Care Center Exception would apply when the teaching physician is supervising a resident with six months or less in an approved Graduate Medical Education (GME) residency program, as well as residents with more than six months in such a program.
Follow the General Teaching Physician Rule
Services furnished by residents in residency programs are excluded from being paid as “physician services” under Medicare Part B because the Medicare fiscal intermediary, Medicare Part A, already pays teaching hospitals for the services of interns and residents, and the costs associated with the supervisory services of teaching physicians. Ordinarily, to be reimbursed under Medicare Part B, services furnished in teaching settings must meet one of the following requirements:
- The service must be personally furnished by a physician who is not a resident.
- The service must be furnished by a resident where a teaching physician was physically present during the critical or key portions of the service.
- The service provided must be a specified service (See the Applicable Procedure Codes information box) furnished by a resident under the Primary Care Center Exception.
What Is the Primary Care Center Exception?
An exception to the general teaching physician rule is sometimes referred to as the “Primary Care Center Exception,” but this exception is not limited to primary care or family practice residency programs. Per CMS, the exception could apply to any residency program with requirements that are incompatible with the teaching physician physical presence requirement. This is because in some residencies, the resident is the patient’s primary caregiver, and it is beneficial for the resident to see patients alone to learn medical decision-making, and to recognize his or her own limitations. Direct teaching physician involvement in these cases may negatively affect the patient-resident relationship. Some examples of residency programs most likely to qualify for the exception are: family practice, general internal medicine, geriatrics, and pediatrics.
Specified services performed under the exception may be billed to Medicare Part B under the teaching physician’s provider number, without the need for the teaching physician to personally perform the service or to be physically present during the critical or key portions of the service.
Attest in Writing
For the exception to apply, the center must attest in writing to the Medicare Part B administrative contractor (MAC) that the following conditions have been met:
- The services are performed in a center that is located in an outpatient department of a hospital or another ambulatory care entity in which the time spent by the residents in patient care activities is included in determining Medicare Part A payments to the hospital.
- The residents involved have completed more than six months of a residency program.
- The teaching physician directs the care of no more than four residents at a time and directs the care from such proximity as to constitute immediate availability.
- The teaching physician has no other responsibilities at the time (including the supervision of other personnel) and assumes management responsibility for those patients seen by the residents.
- The patients seen are an identifiable group who consider the center to be the continuing source of their health care and are cognizant that services are furnished by residents under the medical direction of teaching physicians. The residents must generally follow the same group of patients throughout the course of their residency program.
Centers exercising the exception must maintain records demonstrating they qualify for the exception.
Teaching Physician Documentation Requirements Under the Exception
The teaching physician must document the extent of his or her participation in the review and direction of the services furnished to each patient.
Teaching Physician Note Example
I have reviewed with the resident Jane Doe’s medical history, physical examination, diagnosis, and results of tests and treatments and agree with the patient’s care as documented in the resident’s note.
Services Included Under the Exception
The range of services furnished by residents under the exception includes:
- Acute care for undifferentiated problems or chronic care for ongoing conditions, including chronic mental illness
- Coordination of care furnished by other physicians and providers
- Comprehensive care not limited by organ system or diagnosis
Know Procedure Code Restrictions
Under the exception, MACs may make physician fee schedule payment for reasonable and necessary, low- to mid-level evaluation and management (E/M) services, and other specified services, when furnished by a resident without the presence of a teaching physician. Refer to the Applicable Procedure Codes information box for a list of specific procedure codes that may be billed under the exception.
Append Modifiers Properly
Modifier GE This service has been performed by a resident without the presence of a teaching physician under the primary care exception must be appended to services billed under the exception. Services furnished in a primary care exception center that do not meet the requirements for the exception would revert to the general teaching physician rule for services furnished outside of a primary care exception center. Modifier GC This service has been performed in part by a resident under the direction of a teaching physician would be appended to these services.
Applicable Procedure Codes
CPT® Codes
New patient office or other outpatient visit: 99201, 99202, and 99203
Established patient office or other outpatient visit: 99211, 99212, and 99213
HCPCS Level II Codes
G0402 Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment
G0438 Annual wellness visit, includes a personalized prevention plan of service (PPPS), first visit
G0439 Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit
Follow 4-to-1 Ratio Rules
As mentioned, the teaching physician under whose name payment is sought must not supervise more than four residents at any given time. CMS recently provided manual guidance clarifying that teaching physicians may include residents with less than six months in a residency program in the mix of four residents under the teaching physician’s supervision. The teaching physician would have to be physically present for the critical or key portions of the services furnished by the resident with less than six months in a residency program. That is, the exception would not apply in the case of the resident with less than six months in a residency program. Because the exception would not apply in this case, modifier GC would be appended to the service, rather than modifier GE. The fact that one or more of the residents has less than six months in a residency program does not affect the application of the exception to the other residents with more than six months in a residency program. The 4-to-1 ratio of residents to teaching physician must not be exceeded, in any case.
Sample Scenarios with 4-to-1 Ratio
Resident with 6 months or less in residency program.
New resident A
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Resident with more than 6 months in residency program.
Old resident B
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Resident with more than 6 months in residency program.
Old resident C
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Resident with more than 6 months in residency program.
Old resident D
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Exception applies to old residents B, C, and D, but not to new resident A. Follow general TP rules for new resident A.
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Apply modifier GC to charge for new resident A. Apply modifier GE to charges for residents B, C, and D.
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Resident with 6 months or less in residency program.
New resident A
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Resident with more than 6 months in residency program.
Old resident B
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Resident with more than 6 months in residency program.
Old resident C
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Resident with more than 6 months in residency program.
Old resident D
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Resident with more than 6 months in residency program.
Old resident E
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Exception does not apply to ANY residents because the 4-to-1 ratio is exceeded. Follow general TP rules for ALL residents.
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Apply modifier GC to charges for ALL residents.
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Resident with 6 months or less in residency program.
New resident A
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Resident with 6 months or less in residency program.
New resident B
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Resident with more than 6 months in residency program.
Old resident C
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Resident with more than 6 months in residency program.
Old resident D
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Exception applies to old residents C and D, but not to new residents A and B. Follow general TP rules for new residents A and B.
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Apply modifier GC to charges for ALL residents.
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Become Familiar with These Key Definitions
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An individual who participates in an approved graduate medical education (GME) program, or a physician who is not in an approved GME program but who is authorized to practice only in a hospital setting. The term includes interns and fellows in GME programs recognized as approved for purposes of direct GME payments made by the fiscal intermediary (Medicare Part A). Receiving a staff or faculty appointment or participating in a fellowship does not by itself alter the status of “resident.” This status remains unaffected regardless of whether a hospital includes the physician in its full time equivalency count of residents. This term is not applicable to medical students.
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A physician (other than a resident) who involves residents in the care of his or her patients.
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A hospital engaged in an approved GME residency program in medicine, osteopathy, dentistry, or podiatry.
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Any provider, hospital-based provider, or non-provider setting in which Medicare payment for the services of residents is made by Medicare Part A under the direct GME payment methodology or freestanding skilled nursing facilities (SNFs) or home health agencies (HHAs) in which such payments are made on a reasonable cost basis.
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The teaching physician is located in the same room (or partitioned or curtained area, if the room is subdivided to accommodate multiple patients) as the patient and performs a face-to-face service.
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Maryann C. Palmeter, CPC, CENTC, is director of physician billing compliance for University of Florida Jacksonville Healthcare, Inc., and provides professional direction and oversight to the billing compliance program at the University of Florida College of Medicine-Jacksonville. She has over 29 years of health care experience in both government contracting and physician billing. She is the education officer and two-time past president of the Jacksonville, Fla. chapter. Ms. Palmeter is AAPC’s 2010 Member of the Year, and is a member of the AAPC National Advisory Board.
November 1st, 2011