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E/M CodingThere occurred significant changes in CPT medical coding this year with an estimated 264 new codes, 143 deleted codes, and 134 revised codes and most of these codes do have an effect on primary care physicians. The significant changes in evaluation and management (E/M) section greatly impact physician coding. The changes are introduced for advance care planning, E/M prenatal visit guidance and care management services. Following are some details regarding these changes.

Advance Care Planning

Advance care planning is a new subsection under E/M section and two codes are included in this section:

  • 99497: Advance care planning for the first 30 minutes
  • 99498: Add-on code assigned for each additional 30 minutes

These time-based codes are used to report face-to-face discussion of advance directives, with or without completing relevant legal forms. The face-to-face visit include those between physician or other qualified healthcare professional (QHCP) and a patient, family member, or surrogate. As per the CPT manual, an advance directive is a document appointing an agent and/or recording the wishes of a patient pertaining to his/her medical treatment at a future time should he/she lack decisional capacity at that time. Certain examples of advance directives are health Care Proxy, Living Will, Medical Orders for Life-Sustaining Treatment (MOLST) and durable power of attorney for healthcare.

Advance care planning codes can be billed with the following E/M services:

  • New and established patient office visits (99201-99215)
  • Observation initial, subsequent and discharge care codes (99217-99220, 99224-99226)
  • Initial, subsequent and discharge hospital service codes (99221-99233, 99238-99239)
  • Observation or inpatient admit and discharge on the same date (99234-99236)
  • Outpatient and inpatient consultations (99241-99255)
  • Emergency department visit codes (99281-99285)
  • Initial, subsequent and discharge nursing facility care codes (99304-99316)
  • Annual nursing facility assessment code (99318)
  • New, established and discharge domiciliary or rest home visit codes (99234-99337)
  • New and established patient home visit codes (99341-99350)
  • Initial and periodic preventive medicine codes (99381-99397)
  • Transitional Care Management Service codes (99495-99496)

However, you can’t bill these codes with critical care codes (99291, 99292), inpatient neonatal and pediatric critical care codes (99468-99476) or initial and continuing intensive care services (99477-99480). Also, Medicare will not pay for advance care planning codes this year and you have to ensure that your commercial payers are paying for these codes before submitting the claims.

Care Management

‘Complex Chronic Care Coordination’ has been changed to ‘Care Management Services’ and a new code 99490 has been added. New subsection ‘Chronic Care Management Services’ has been added to reflect the management services described by the new code. The code 99490 is used to report chronic care management services that take at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month, along with the following required elements:

  • Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
  • Chronic conditions that put the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
  • Comprehensive care plan established, implemented, revised, or monitored

Medicare will reimburse for this code instead of G-code proposed earlier.

E/M Prenatal Visit Guidance

The guidelines for maternity care and delivery were revised and you should now take care of the following:

  • If pregnancy is confirmed during a problem-oriented or preventive visit, it won’t be considered as a part of ante-partum care. You should report the appropriate E/M code for such a visit.
  • The initial prenatal history and physical examination are included in the ante-partum care.

In addition to these changes, there has been an expansion in E/M guidelines for social history and now includes a bullet for Military History. You should take care of this while documenting for E/M services. If you are confused with the new E/M codes, consider getting help from a medical coding expert having thorough knowledge in the latest coding updates and compliance details.