Establish New CPT® Evaluation & Management Rules for 2012

Successfully apply E/M code modifications in several service categories.

With the release of CPT® 2012, evaluation and management (E/M) guidelines have been updated to clarify the meaning of “new” vs. “established” patients, and code use has been modified for several service categories. Here’s what you need to know to apply these changes successfully.

Three-year Rule Applies to Same Group, Same Subspecialty

Clarifying the definition of new vs. established patients, CPT® now states, “A new patient is one who has not received any professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.” This is a restatement of the familiar “three-year rule,” but is significant in allowing a physician to bill a new patient service (e.g., 99202–99205), even if another physician in the group practice has seen the patient within the past three years—as long as the physicians are of a different specialty/subspecialty.

Certified Pediatrics Coder CPEDC

To make the new/established determination easier, CPT® 2012 Professional Edition reintroduces the “Decision Tree for New vs. Established Patients” to the E/M Services Guidelines.

The E/M Services Guidelines further clarify, “Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT® code(s).” A patient might still be new, for instance, if the physician had interpreted test results a month earlier, but had provided no face-to-face services within the previous three years.

Initial Observation Care Can Be Time-based

Many E/M service codes include a reference time: For instance, the descriptor for established outpatient visit code 99214 specifies, “Physicians typically spend 25 minutes face-to-face with the patient and/or family.” The reference time allows you to report a service based on time (rather than the key components of history, exam, and medical decision-making (MDM)) when “counseling and/or coordination of care dominates (more than 50 percent) of the physician/patient and/or family encounter,” per CPT® instructions.

As an example, the physician spends 30 minutes with an established patient who has been newly diagnosed with type 2 diabetes. During the entire visit, the physician discusses lifestyle changes to help manage the disease and answers questions from the patient and the patient’s wife. Based on the key components of history, exam, and MDM, the visit might not support even the lowest-level service. If the physician documents his counseling and the nature of the discussion, however, a level IV visit (99214) could be supported based on time alone.

For 2012, reference times have been added to initial observation care codes, which did not previously include them (See table below for new language in code descriptor).

2012 Added Code Verbiage

CPT®

New Language Added to End of Code Descriptor

99218 Physicians typically spend 30 minutes at the bedside and on the patient’s hospital floor or unit
99219 Physicians typically spend 50 minutes at the bedside and on the patient’s hospital floor or unit
99220 Physicians typically spend 70 minutes at the bedside and on the patient’s hospital floor or unit

Time attributed to the service must be face-to-face with the patient and/or decision makers, or may include unit/floor time in the hospital or nursing facility. Adding reference times to these codes also allows for the use of prolonged services in addition to the initial observation care.

Prolonged Services Get an Overhaul

CPT® 2012 adds significant new text directing proper use of prolonged services codes 99354–99357. It defines direct patient contact as “face-to-face,” but also counts “additional non face-to-face services on the patient’s floor or unit of the hospital or nursing facility during the same session.” All codes report the total time duration of care (time does not have to be contiguous), and are in addition to other E/M services that include reference times. A complete list of such services—now including initial observation care services 99218–99220—may be found following the code descriptors.

The term “face-to-face” has been stricken from the code descriptors to allow unit/floor time to count in the inpatient setting; and the codes no longer apply specifically to physicians, but to physicians and “other qualified health care professionals” (deleted text has been struck through).

+99354   Prolonged physician service in the office or other outpatient setting requiring direct patient (face to face) contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient evaluation and management service)

+99355       each additional 30 minutes (List separately in addition to code for prolonged physician service)

+99356   Prolonged physician service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient evaluation and management service)

+99357      each additional 30 minutes (List separately in addition to code for prolonged physician service)

Either 99354 or 99356 (depending on the setting) is used to report the first 30-74 minutes of prolonged care (above and beyond the reference time for the primary E/M service). Report only a single unit of 99354 or 99356 per date of service. Codes 99355 and 99357 may be used to report each additional 15-30 minutes of prolonged service beyond the first hour. You may not separately report prolonged services of fewer than 30 minutes.

For example, the physician provides a two-hour counseling/coordination of care session with an established patient just diagnosed with a chronic, but controllable illness. The reference time for the highest-level established outpatient code (99215) is 40 minutes. The physician has provided 80 minutes of service beyond the reference time. If supported by documentation, the physician would report 99215 for the first 40 minutes, 99354 for the next hour, and 99355 for the remaining 20 minutes.

Codes for prolonged services without direct patient contact (99358–99359) have undergone similar revisions; for instance, the codes now apply to physicians and other qualified health care professionals (not just physicians). These codes specifically apply to extensive record review or other time not spent face-to-face with the patient/caregiver or unit/floor time in the hospital or nursing facility. The services need not be provided on the same day as the primary service, and the primary service does not have to include a reference time.

More Services Are Included in Neonatal/Pediatric Critical Care

Lastly, CPT® includes some new language in the guidelines directing use of inpatient neonatal and pediatric critical care (99468–99472) intensive services (99475–99476) codes, and for initial and continuing intensive care services (99477).

Many services/procedures are bundled to critical care, including vascular access and lumbar puncture, to name a few. This year, car seat evaluation (as reported with new codes 94780–94781) has been added to the list of bundled procedures.

Physicians may separately report any services not specifically enumerated by CPT® as included in 99468–99472 and 99475–99476; facilities, however, may separately report even the included services.

New instructions have also been added to clarify billing when a critically ill neonate or pediatric patient is transferred to lower-level care. CPT® specifies “the transferring physician does not report a per day critic care service.” Instead, either 99231–99233 (subsequent hospital care) or 99291–99293 (critical care) is reported. The receiving physician reports “subsequent intensive care (99478–99480) or subsequent hospital care (99231–99233), as appropriate based upon the condition of the neonate or child.”

Similarly, when a neonate is transferred from intensive care (99477) to a lower-level care, the transferring physician should report subsequent hospital care (99231–99233). If the neonate or infant must be transferred to critical care on a day when initial or subsequent intensive care services have been performed, the transferring physician may report either the critical care (99291-99292) or the intensive care (99477), but not both. The receiving physician may report subsequent inpatient neonatal or pediatric critical care (99469 or 99472).

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G.J. Verhovshek, MA, CPC, is managing editor at AAPC.

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