2018 Brings New Focus to E/M Services
CPT® code and guideline changes show a shift towards collaborative care and behavioral health management.
With the release of CPT® 2018, we see major changes in coding throughout the Evaluation and Management (E/M) section. New codes and chapters were added for collaborative care management (CoCM) and behavioral health management. Let’s review these complex changes, which went into effect Jan. 1.
New! Cognitive Assessment and Care Plan Services
New code 99483 Assessment of and care planning for a patient with cognitive impairment, requiring an independent historian, in the office or other outpatient, home or domiciliary or rest home replaces deleted HCPCS Level II code G0505. With code 99483, typically 50 minutes are spent face-to-face with the patient and/or family or caregiver. Cognitive assessment and care plan services are provided when a comprehensive evaluation of a new or existing patient, who exhibits signs and/or symptoms of cognitive impairment, is required to establish or confirm a diagnosis, etiology, and severity for the condition. This service includes a thorough evaluation of medical and psychosocial factors, potentially contributing to increased morbidity.
Do not report cognitive assessment and care plan services if any of the required elements are not performed or are deemed unnecessary for the patient’s condition. For these services, see the appropriate E/M code. Cognitive assessment and care planning may be reported every 180 days, but not with other E/M services.
New! Psychiatric CoCM Services
Three new codes (99492-99494) report initial and subsequent psychiatric CoCM. Per the American Psychiatric Association, CoCM services:
…typically [are] provided by a primary care team consisting of a primary care physician and a care manager who work in collaboration with a psychiatric consultant, such as a psychiatrist. Care is directed by the primary care team and includes structured care management with regular assessments of clinical status using validated tools and modification of treatment as appropriate. The psychiatric consultant provides regular consultations to the primary care team to review the clinical status and care of patients and to make recommendations.
To report CoCM, all bulleted items must be performed and documented, and the time threshold must be met, as demonstrated in Table A. Do not report 99492 Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health care manager activities with 99493 Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities in the same month.
|Type of Service||Total Duration of Collaborative Care Management Over a Calendar Month||Code(s)|
|Initial- 70 minutes||Less than 36 minutes
(36 minutes- 1 hour 25 minutes)
|Not reported separately 99492|
|Initial plus each additional increment up to 30 minutes||86-116 minutes
(1 hour 26 minutes- 1 hour 56 minutes)
|99492 x 1 AND 99494 x 1|
|Subsequent 60 minutes||Less than 31 minutes
(31 minutes – 1 hour 15 minutes
|Not reported separately 99493|
|Subsequent plus each additional increment up to 30 minutes||76-105 minutes
(1 hour 16 minutes- 1 hour 45 minutes)
|99493 x 1 AND 99494 x 1|
New! General Behavioral Health Integration Care Management
New code 99484 Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional, per calendar month replaces HCPCS Level II code G0507 to report general behavioral health integration (BHI) services, which incorporate principles associated with collaborative care. To report these services, all bulleted items listed in the code descriptor must be performed and documented, and the time threshold (in this case, at least 20 minutes) must be met. Do not report 99484 with 99492, 99493, +99494 Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional (List separately in addition to code for primary procedure) in the same month.
Anticoagulation Management Gets an Overhaul
Codes 99363 and 99364 for anticoagulation management are deleted and replaced by new (Medicine section) codes:
93792 Patient/caregiver training for initiation of home international normalized ratio (INR) monitoring under the direction of a physician or other qualified health care professional, face-to-face, including use and care of the INR monitor, obtaining blood sample, instructions for reporting home INR test results, and documentation of patient’s/caregiver’s ability to perform testing and report results
93793 Anticoagulant management for a patient taking warfarin, must include review and interpretation of a new home, office, or lab international normalized ratio (INR) test result, patient instructions, dosage adjustment (as needed), and scheduling of additional test(s), when performed
Due to the critical nature of thinning blood or reducing its clotting factor, patients on warfarin require constant oversight and international normalized ration (INR) testing. The medication is adjusted, as needed, to provide the best level of anticoagulation in the blood. The patient is reminded of the specific dietary needs, and observed for possible bruising. Anticoagulation management codes are used to report this oversight, which includes ordering, reviewing, and interpreting the INR testing, communicating with the patient, and adjusting dosage, as necessary. Code 93792 reports the education for the patient or caregiver for home INR monitoring; 93793 reports the provider’s management and oversight.
Revised! Guidelines for Initial Observation Care and More
New text clarifies that initial observation codes 99218-99220:
… report the encounter(s) by the supervising physician or other qualified healthcare professional with the patient when designated as a hospital “observation status.” This refers to the initiation of observation status, supervision of the care plan for the observation, and performance of periodic reassessments. For observation encounters by other physicians, see office or other outpatient consultation codes (99241-99245) or subsequent observation care (99224-99226) as appropriate.
The term “outpatient hospital” was added to code descriptors to clarify that observation services (including 99217 Observation care discharge day management) are specific to outpatient status (POS 22 On campus-outpatient hospital). Do not report observation for patients admitted to the hospital.
There are several important changes to the E/M guidelines and parenthetical instructions.
New guidelines clarify that prolonged service codes 99354-99357 involve direct patient contact, beyond the usual service, in either the inpatient or outpatient setting. The guidelines define direct patient contact as “face-to-face,” but further include “additional non-face-to-face services on the patient’s floor or unit in the hospital or nursing facility during the same session.”
New guidelines explain that telephone services codes 99441-99443 are not reported with 93792, 93793 for home and outpatient INR monitoring.
Revised guidelines clarify that time-based critical care services (99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes and +99292 Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service)) may not be reported by the same individual (or a different individual of the same specialty or group) when reporting neonatal or pediatric critical care services (99468-99476) for the same patient on the same day, but may be reported by an individual of a different specialty (from either the same or different group) on the same day as neonatal or pediatric critical care services.
Per CPT®, “Critical care interfacility transport face-to-face (99466, 99467) or supervisory (99485, 99486) services may be reported by the same or different individual of the same specialty and same group, when neonatal or pediatric critical care services (99468-99476) are reported for the same patient on the same day.”