Welcome to the "Biller’s Corner" of the pMD blog, your trusted source for updates, tips, and tricks provided by seasoned medical billing and coding experts!
Medical coding is often a moving target, especially during a pandemic. But have no fear, we’re here to provide guidance on some recent coding updates you need to know about!
Speaking of the pandemic, new codes were released for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative-free, 5×1010 viral particles/0.5mL dosage, for intramuscular use.Here’s what you need to know:
* This is the code used for the one-dose COVID-19 vaccine developed by Janssen Pharmaceutica, a division of Johnson & Johnson.
* It should be used in conjunction with the CPT code 0031A, Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative-free, 5×1010 viral particles/0.5mL dosage, single dose.
Another hot topic this year has been the significant updates to E/M office codes (99201-99215). The primary intention behind the changes is to reduce the administrative burden of unnecessary documentation, in turn, allowing for more time to interact with patients. While the intention is great, there has been a lot of confusion surrounding the revisions made to this code set, and many physicians have reported that the ambiguity of the new revisions is actually leading to additional time spent on documenting. This is obviously the opposite of what they were going for, so the AMA is acting on that feedback and has released the following revisions, retroactive to January 1, 2021.
For time-based billing, you should not account the following:
* Performance of other services when reported separately
* Travel time
* Teaching that is not required for the management of the specific patients' care
Also, remember Medicare and private payers’ policies can differ when it comes to reporting prolonged services for time-based billing. Although the AMA has established the CPT 99417, Medicare has assigned a status indicator of “I” for this code which denotes the code as invalid. Instead, Medicare will accept HCPCS code G2212 when reporting 15 minutes of prolonged care, performed on the same encounter as E/M codes 99205 and 99215. When billing for either code, be sure that it is listed separately in addition to a level 5 office/outpatient E/M service.
When it comes to medical decision making (MDM), you should account for tests that are analyzed as part of MDM and are not reported separately when interpreting the study. These may be counted as ordered or reviewed when selecting an MDM level. When determining the complexity of problems and the number of problems addressed, also consider the following:
* If the presenting symptoms are likely to represent a highly morbid condition, this may “drive” MDM even when the ultimate diagnosis is not highly morbid. Multiple low severity conditions may equate to a higher risk level due to interaction.
* When determining data reviewed and analyzed, pulse oximetry is not considered a test.
* When considering data elements reviewed, a combination of three data elements can be counted by reporting a unique test ordered, plus a note reviewed and an independent historian. However, it does not require each item type or category to be represented.
* Ordering a test may include those considered, but not selected after shared decision making due to patient health risk or a discussion to forego further testing due to lack of medical necessity.
The AMA has also provided clearer instructions to interpret the definitions that make up the elements of MDM. Understanding the following terms as they are laid out by the AMA is crucial:
* Analyzed: Tests ordered are presumed to be analyzed when the results are reported. Therefore, when they are ordered during an encounter, they are counted in that encounter. Tests that are ordered outside of an encounter may be counted in the encounter in which they are analyzed.
* Discussion: Discussion requires an interactive exchange. The exchange must be direct and not through intermediaries (eg, clinical staff or trainees). The discussion can be asynchronous and occur on a later date following the encounter but must be completed within a short time period (eg, within a day or two).
* Independent Historian: When collecting the history, it does not need to be obtained in person but does need to be obtained directly from the historian providing the information.
* Risk: The term “risk” as used in these definitions relates to risk from the condition. While condition risk and management risk may often correlate, the risk from the condition is distinct from the risk of the management.
* Surgery (minor or major): The classification of surgery into minor or major is based on the common meaning of such terms when used by trained clinicians, similar to the use of the term “risk.” These terms are not defined by a surgical package classification. Be advised that CPT guidelines indicate that it is the provider's clinical determination whether surgery is considered major or minor and is not dictated by global days. However, if the surgery occurs in an office setting, you will have a hard time justifying it as a major surgery. Major surgeries will most often require the use of an operating room.
* Surgery (elective or emergency): Elective procedures and emergent or urgent procedures describe the timing of a procedure as it relates to the patient’s condition. An elective procedure is typically planned in advance and scheduled, while an emergent procedure is typically performed immediately or with minimal delay to allow for patient stabilization. Both elective and emergent procedures may be minor or major procedures.
* Surgery (risk factors): Risk factors are those that are relevant to the patient and procedure. Evidence-based risk calculators may be used, but are not required, in assessing patient and procedure risk.
A full list of revisions can be found on the AMA website. Plus, be on the lookout for even more revisions that will become effective in 2023. Make sure to check back in soon for more billing and coding updates! And if you are interested in learning more about pMD’s billing and revenue cycle management services, please contact us here or give us a call at 800-587-4989 x2. We’d love to hear from you!
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