CMS revises rules for E/M documentation, hospital discharges

This year's Current Procedural Terminology (CPT) code changes are significant for internal medicine. The new code set clarifies the hospital discharge management codes, the prolonged services codes, and the transitional care management and complex chronic care management codes. Also new to the code set are interprofessional telephone/Internet consultation codes, which should be of particular interest to internal medicine specialists and subspecialists.

There are far too many changes throughout the code set to list in this column. ACP advises that its members determine which codes they use most frequently and then check the new CPT codes to be aware of any changes.

E/M services

Art 1

First, beginning with services performed on or after Sept. 10, physicians may use the 1997 documentation guidelines for an extended history of present illness along with other elements from the 1995 guidelines to document evaluation and management (E/M) services. The Centers for Medicare and Medicaid Services (CMS) met significant criticism when it published its guidelines on documenting E/M services in 1995 and subsequently revised them in 1997. The agency allowed both versions to remain in use but previously prohibited physicians from combining the 2 versions for documenting a single encounter.

Hospital discharge

Regarding the codes for 99238 and 99239 (hospital discharge day management), before the 2014 revision, there was some question about how the hospital services of various physicians and providers should be reported when performed on the discharge date. The new parenthetical statement following these codes was revised to clarify those questions. (For Medicare claims, admitting physicians should also append modifier “AI” to the visit code.) Going forward, physicians or qualified health care professionals who are not the discharging physician should report their concurrent, discharge day care by using the subsequent hospital care codes (99231-99233).

Prolonged services

The parenthetical guidance for codes 99354 and 99355 (prolonged services) states that they may be used in conjunction with code 90837 (psychotherapy, 60 minutes with patient and/or family member).

Revisions to complex care codes

The guidelines for complex chronic care coordination services were revised, at the request of ACP and other specialty societies, to better define appropriate use. The revision clarifies the patient population, the definition of a practice, the care plan description, and the reporting requirements.

To reduce duplicative coding, the care plan oversight nursing facility codes 99379 and 99380 were added to the range of those that should not be reported with the complex chronic care coordination services codes. The revised code ranges are included in the guidelines and the exclusionary statement following code 99489 (complex chronic care management).

Interprofessional consultations

There is a set of new codes to report interprofessional (“doctor-to-doctor”) telephone/Internet consulting. Code 99446 is defined as an interprofessional telephone/Internet assessment and management service provided by a consultative physician, including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional, and involves 5 to 10 minutes of medical consultative discussion and review. Related codes include the following:

  • 99447: 11 to 20 minutes of medical consultative discussion and review
  • 99448: 21 to 30 minutes of medical consultative discussion and review
  • 99449: 31 minutes or more of medical consultative discussion and review

There are a number of considerations to make before reporting these codes. Be certain to refer to the 2014 CPT for complete details and coding guidance.

The consulting physician is the one who bills this service, not the physician who requested the consult. The consulting physician offers specific specialty expertise that will assist the treating physician or other qualified health care professional in the diagnosis and/or management of the patient's problem without the need for the patient and consultant to meet face-to-face.

Conversely, the treating/requesting physician may report the prolonged service codes 99354, 99355, 99356 or 99357 for time spent on the interprofessional telephone/Internet discussion with the consultant if the time exceeds 30 minutes beyond the typical time of the appropriate E/M service performed and if the patient is present (on-site) and accessible to the treating/requesting physician. Or, if the interprofessional telephone/Internet assessment and management service occurs when the patient is not present or on-site, and the discussion time exceeds 30 minutes beyond the typical time of the appropriate E/M service performed, then the non-face-to-face prolonged service codes 99358 and 99359 may be reported by the treating/requesting physician.

The services will typically be provided in complex and/or urgent situations where a timely face-to-face service with the consultant may not be possible. The written or verbal request, its rationale, and the conclusion for telephone/Internet advice by the treating/requesting physician or other qualified health care professional should be documented in the patient's medical record.

The codes must not be reported by a consultant who has agreed, before the telephone/Internet assessment, to accept a transfer of care. However, if the decision to accept a transfer of care cannot be made until after the initial interprofessional telephone/Internet consultation, the codes are appropriate to report.

The patient may be either new to the consultant or an established patient with a new problem or an exacerbation of an existing problem. However, the patient should not have been seen by the consultant in a face-to-face encounter within the previous 14 days.

Do not report the codes when the telephone/Internet consultation leads to an immediate transfer of care or other face-to-face service (e.g., a surgery, a hospital visit, or a scheduled office evaluation of the patient) within the next 14 days. When multiple telephone/Internet contacts are required to complete the consultation request (e.g., discussion of test results), the cumulative service and review time should be reported with a single code.

Telephone/Internet consults of less than 5 minutes should not be reported. Consultant communications with the patient and/or family may be reported using 99441, 99442, 99443, 99444, 98966, 98967, 98968 or 98969, and the time related to these services is not used in reporting interprofessional telephone/Internet consult codes 99446, 99447, 99448 or 99449.