American College of Physicians: Internal Medicine — Doctors for Adults ®


2007 rings in changes to anticoagulation management

The new year also brings new language to clarify reimbursement for consultations, screenings and vaccines.

From the January-February ACP Observer, copyright 2007 by the American College of Physicians.

By Brian Whitman

The New Year always brings changes to the world of coding and billing, and 2007 is no different. Among the changes are new codes for anticoagulation management, originally proposed by the College, that were intended to more fairly compensate physicians for managing the care of patients on warfarin.

Although there are some new codes that are in the CPT book that internists should be aware of, a Medicare payment decision may delay the use of these codes for most practicing physicians.

Anticoagulation Management

Q: I noticed in my CPT book that there are now codes for anticoagulation management. Can I use those codes for my patients?

A: The Current Procedural Terminology (CPT) Panel, a committee made up of members appointed by the American Medical Association (AMA), approved the creation of two new codes for anticoagulation management in the 2007 CPT book: 99363 and 99364.

These codes are intended to be used for the active management of a patient on anticoagulation (warfarin) therapy and would require the physician to submit a bill every 90 days. Code 99363 is for the initial 90 days of therapy while 99364 applies to the subsequent 90 days of therapy.

99363 is intended to be used at the conclusion of the initial 90 days of outpatient warfarin therapy. The code is intended to cover the work involved in adjusting warfarin levels based on a review of a patient's INR measurements. The code language requires that a physician record at least eight INRs in the 90-day period in order to report the code. Any work that a physician did related to this management could not be considered when determining the level of any evaluation and management (E/M) code reported during this time period. The physician would bill the code on the 90th day of management.

99364 is very similar but is to be used for subsequent 90-day periods of management and only requires three INR measurements.

Q: How much will I be paid for these codes?

A: CMS, with the publication of the 2007 Physician Fee Schedule Final Rule, announced that Medicare will not separately pay for these codes in 2007, considering the services to be bundled into the E/M codes that physicians already report. Other payers have not made their plans clear, but no payer has yet announced that it will pay for this service. If this situation changes, a more detailed educational piece about the use of these codes will appear in this column.

Q: What should physicians do?

A: Physicians may continue to handle their patients on warfarin therapy as in the past and consider the work when selecting the level of E/M service. A detailed explanation of anticoagulant billing in 2000 is available online.

Changes in Payment

Q: I recently heard in the news that physician payments from Medicare would not be reduced by 5% as planned but instead remain the same. Does this mean that the payment for all of my codes will stay exactly the same?

A: The news that Congress stepped in to avert the planned 5% cut was good for doctors and the result of hard work from many in the physician community who contacted their elected representatives. For internists and other physicians who do a great deal of E/M services, 2007 will be a better year for Medicare payments than 2006.

Fee-setting for Medicare is a complicated process, and CMS is required to undertake a review of the values of physician payments every five years. The biggest change this year was the CMS decision to increase the values for many evaluation and management services. In general, higher-level codes received greater increases than lower-level codes.

CMS estimates that the Medicare reimbursement for the average general internist will increase by 5% from 2006 to 2007. This average may vary based on patient illness and medical specialties all have different projected changes. Private payers often follow the lead of Medicare in making payment decisions, but the implications of the Medicare decision on the private sector are unclear at this time.

Other issues

Q: Are there any other issues that I should know about?

A: Some of the other changes that internists should be aware of include:

  • New language in the consultation section of the CPT book emphasizes that only one inpatient consultation may be reported per physician per admission. This is a follow-up to the 2006 deletion of the confirmatory and subsequent consultation codes. To further clarify, the word "initial" has been deleted from the inpatient consultation description, as there can only be one consultation.
  • Medicare will now pay its total allowed amount for colorectal screenings, which have been a covered benefit under Medicare for a number of years. Patients receiving the screenings will no longer be required to pay Medicare's typical 20% copay. This is only for the Medicare-specific G codes for preventive services (G0104, G0105, G0106, G0107). Medicare has gradually added coverage for preventive benefits through Congressional action, and the elimination of this barrier should encourage more patients to receive this screening. Unfortunately, Medicare still does not cover an E/M service related to a preventive service even if it is needed prior to the provision of a colorectal cancer screening.
  • The descriptors for vaccines and toxoids in many cases included the phrase "for use in individuals age X to X." This phrase has been deleted and replaced by the phrase "when administered to individuals age X to X." This change is intended to more clearly indicate which code a physician should use when providing a vaccine.

Brian Whitman is Senior Analyst for Regulatory and Insurer Affairs in ACP's Washington office.


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