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

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Variety of coding changes loom for 2013

From the November/December ACP Internist, copyright 2012 by the American College of Physicians

By Debra Lansey

ACP previously reported that CMS would soon begin using a “partial freeze” on diagnosis coding updates. The partial freeze would incrementally phase out the ICD-9 annual updates, so that future changes will reflect only new technology and diseases.

Because the compliance date for ICD-10 has been pushed back one year, the ICD-9-CM Coordination and Maintenance Committee, which includes an ACP representative, decided to also extend the partial code freeze by one year. There was considerable support for this partial, extended freeze.

Variety of coding changes loom for 2013

Here is the revised ICD-9 update schedule:

  • The last regular, annual updates to both the ICD-9-CM and ICD-10 code sets were made on Oct. 1, 2011.
  • On Oct. 1, 2012, only limited code updates were made to the ICD-10 code set to capture new technologies and diseases; no additions, deletions or revisions were made to the ICD-9-CM code set. Both code sets will again receive only limited code updates on Oct. 1, 2013.
  • On Oct. 1, 2014, there will be only limited code updates to the ICD-10 code set. There will be no updates to ICD-9-CM because it will no longer be used for reporting.
  • On Oct. 1, 2015, regular updates to ICD-10 will begin.
New care management codes

New care management codes will be introduced beginning in 2013. All of these codes represent an innovative step in health claim reporting: the inclusion of non-face-to-face work and time.

ACP has been a strong advocate for allowing physicians to report and be reimbursed for the non-face-to-face care they give their patients. Care for patients with complex, chronic illnesses and for those who have recently been discharged from a hospital or facility has not previously been described in Current Procedural Terminology (CPT) or Health Care Procedure Coding System (HCPCS) codes.

The following summaries offer the highlights of the new codes; more detail about each (who may report them, what kinds of services are included, and which other codes are considered duplicative of the new codes) will be found in the 2013 CPT codebook.

Complex chronic care codes

The complex chronic care management codes below take effect Jan. 1, 2013. However, it is not clear at this time how or whether CMS will use the codes in the Medicare program.

  • 99487: complex chronic care coordination services; first hour of clinical staff time directed by a physician or other qualified health care professional with no face-to-face visit, per calendar month
  • 99488: complex chronic care coordination services; first hour of clinical staff time directed by a physician or other qualified health care professional with no face-to-face visit, per calendar month; first hour of clinical staff time directed by a physician or other qualified health care professional with one face-to-face visit, per calendar month
  • 99489: complex chronic care coordination services; first hour of clinical staff time directed by a physician or other qualified health care professional with no face-to-face visit, per calendar month; each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (list separately in addition to code for primary procedure). (99489 should be reported in conjunction with 99487 and 99488.)

The primary intent of these codes is to allow physicians and qualified health care professionals to report the work and time they spend on a patient’s care, including the non-face-to-face elements. Few other CPT codes explicitly include non-face-to-face work and time.

CPT specifies that these codes will be used by physicians, other qualified health care professionals, and clinical staff for an individual who resides at home or in a domiciliary, rest home, or assisted living facility. As shown in the descriptors, the codes are reported in one-hour or 30-minute segments over the period of a calendar month.

Transition care management codes

Several codes are under consideration for the 2013 Medicare fee schedule. Two CPT codes, 99495 and 99496, will appear in the 2013 CPT codebook. The third and competing code is one proposed by CMS.

CPT 99495 involves transitional care management services with the following required elements:

  • communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge,
  • medical decision making of at least moderate complexity during the service period and
  • a face-to-face visit within 14 calendar days of discharge.

CPT 99496 involves transitional care management services with the following required elements:

  • communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge,
  • medical decision making of high complexity during the service period and
  • a face-to-face visit within seven calendar days of discharge.

The transitional care management codes are intended to report the follow-up care given to patients once they have been discharged from a facility setting to their community setting.

The facility setting may be an acute hospital, rehabilitation hospital, long-term acute care hospital, partial hospital, observation status in a hospital or a skilled nursing facility/nursing facility. The community setting may be the patient’s home, domiciliary, rest home or assisted living.

The CPT transition care codes can be reported by a physician or other qualified health care professional and/or licensed clinical staff under the physician’s direction. The codes encompass one face-to-face visit with the patient after discharge and the non-face-to-face care provided during the service period.

If more than one face-to-face visit occurs within the reporting period, that visit is to be reported separately. The coding guidelines in CPT are specific about the services that are to be included in these two codes. These codes are also effective Jan. 1, 2013.

In its proposed rule for the 2013 Medicare Physician Fee Schedule, CMS proposed a new HCPCS code (unnumbered at the time of this writing) for the transition of a beneficiary from care furnished by a treating physician during a hospital stay, skilled nursing facility stay, or community mental health center stay to care furnished by the beneficiary’s primary physician in the community.

CMS proposes that the post-discharge transitional care HCPCS code be payable only once in the 30 days following a discharge, per patient per discharge, to a single community physician or qualified nonphysician practitioner (or group practice) who assumes responsibility for the patient’s post-discharge transitional care management. The claim would be paid at the conclusion of the 30-day post-discharge period.

A key difference between the CMS proposal and the CPT codes is that the CMS HCPCS code does not bundle a face-to-face visit. This HCPCS code, largely similar to the CPT transition care management codes, was proposed at the same time as the CPT codes in the valuation process.

ACP has closely examined and deliberated over all the codes, including the CPT and CMS versions of transition care management services. Each code offers advantages; each code is a unique take on how to describe care management.

ACP advocates the finalization of the CPT codes and their relative values. This will support the work of the Relative Value System Update Committee (RUC) and emphasize the importance of physician input to the CMS fee schedule process. (More information about ACP’s position is online.)

It will not be known until early November which transition codes will be added to the Medicare fee schedule. At that time, ACP will provide a detailed message to its members about the valuation of these new codes, as well as coding guidance.

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