Many primary care physicians outsource medical billing and coding as they are too focused on providing care and unable to keep up with the changes impacting their field. Professional service providers work with the physicians to ensure that their practice’s coding and documentation practices meet payer rules, which is crucial to optimize practice revenue and reduce the risks of audits. Experienced medical coding and billing specialists are up-to-date on all the CPT and ICD-10 CM changes for 2016 and can help physicians maintain and increase their revenue.
Updates to Family Medicine
Here are some of the major coding and documentation changes that family practices need to be alert about in 2016:
- Official Descriptor Changes in Prolonged Care and Chronic Care Management (CCM) Codes: CPT 2016 has brought descriptor changes in existing codes. The wording of the official descriptors for prolonged care and chronic care management (CCM) codes 99354 and 99355 has changed to indicate that the prolonged service goes beyond the typical time of the procedure.
- 99354 (office or outpatient place of service codes) has to be reported for the first hour of prolonged services. This code should be used only once per date, and prolonged services must exceed 30 minutes to report this service.
- 99355 (office or outpatient place of service codes) has to be reported for each additional 30 minutes beyond the first 60 minutes of prolonged services. Additional services must exceed 15 minutes to report this service.
Other E/M or psychotherapy service has to be listed separately. CPT considers prolonged service codes 99354-99357 as add-on codes and therefore they should not be reported without the appropriate primary code.
- Removal of cerumen from the ear: There is a new code 69210 to bill for removal of cerumen. With this, primary care providers now have a code that better reflects how cerumen is removed. When billing both 69210 (Removal impacted cerumen using irrigation/lavage, unilateral) and an E&M service, the documentation should support the complete performance of both codes. Any same-day E/M has to be shown as significant and separately identifiable using modifier 25. If the payer decides to bundle the new code into an E/M code, the cerumen removal cannot be reported separately.
- Two new Add-On E/M Codes: The following new add-on codes better capture clinical staff performance after the physician provides E/M service:
- +99415 – Prolonged clinical staff service (the service beyond the typical service time) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour (List separately in addition to code for outpatient Evaluation and Management service)
- +99416 – each additional 30 minutes (List separately in addition to code for prolonged service)
- Four new vaccination codes: CPT 2016 has 4 new codes for meningococcus vaccines, for cholera, and for the vaccine for diphtheria, tetanus, pertussis, polio, Haemophilus influenzae type b, and hepatitis B.
- 90620 – Meningococcal recombinant protein and outer membrane vesicle vaccine, serogroup B [MenB], 2 dose schedule, for intramuscular use
- 90621 – Meningococcal recombinant lipoprotein vaccine, serogroup B [MenB], 3 dose schedule, for intramuscular use
- 90625 – Cholera vaccine, live, adult dosage, 1 dose schedule, for oral use
- 90697 – Diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, Haemophilus influenzae type b PRP-OMP conjugate vaccine, and hepatitis B vaccine [DTaP-IPV-Hib¬-HepB], for intramuscular use
- ICD-10 coding changes: ICD-10-CM involves three main categories of changes: definition changes, terminology differences, and increased specificity. Over 1/3 of the expansion of ICD-10 codes is explained by the addition of laterality (left, right, bilateral). Medical coding companies pay special attention to these changes as research have shown that primary care physicians tend to use more diagnostic codes.
Avoiding Errors and Optimizing Reimbursement
The common claim submission errors that family practices face relate to duplicate claims, claims not covered by this payer, bundled services, patient eligibility verification, medical necessity, and non-covered services. As coding and documentation rules become increasingly complex, family physicians are relying on professional medical billing and coding services. The right service provider can help physicians stay abreast of changes, prevent inappropriate coding and erroneous claim submission, avoid payer scrutiny, and maximize revenue.