Oncology & Hematology Coding Alert

Check out the clarification explaining NPP specialties and subspecialties.

Pick any E/M code, and there's a good chance it will be revised for CPT® 2013. The good news is that the long list of revisions is much easier to handle once you recognize the pattern.

The revisions won't be finalized until later this fall, but we've highlighted the proposed changes now to help you prepare for Jan. 1, 2013, implementation.

E/M Codes Get Specific About Providers

Various policies and Medicare rules and regulations have long included references to the term "physician" meaning all providers eligible to bill for services at the levels indicated. That concept applies to E/M codes, allowing several billing providers, such as nurse practitioners and physician assistants, to bill their services directly to the program or under the "incident to" provision.

CPT®, however, has not specifically included this concept, limiting the language in the E/M codes to refer only to "physicians" in their descriptors. But that will change effective Jan. 1, 2013, when the descriptors will add "qualified health care professionals."

Using 99213 as an example, the code changes are indicated with the strikethroughs (indicating deleted text) and underlining (indicating new text) as follows: Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other physicians, other providers qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend Typically, 15 minutes are spent face-to-face with the patient and/or family.

This really isn't a change per se, as much as it is a clarification, says Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, president of Maggie Mac-Medical Practice Consulting.

"They are clarifying that all E/M codes can be reported by physicians or other qualified health care providers and changed the wording with regard to time in each of the codes " which really has no bearing on how the codes are used, just that the typical time is spent by all qualified providers who bill these codes," says Melanie Witt, RN, COBGC, MA, an independent coding consultant in Guadalupita, N.M. "In other words, if a payer allows someone other than a physician to provide and bill for a service, the CPT® E/M codes are used by all providers who qualify."

Qualified defined: CPT® guidelines state: "A 'physician or other qualified health care professional' is an individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his or her scope of practice and independently reports that professional service. These professionals are distinct from 'clinical staff.' A clinical staff member is a person who works under the supervision of a physician or other qualified health care professional, and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specific professional service, but does not individually report that professional service."

So the language change clarifies things in two ways. First, the "E/M service changes indicate nonphysician providers (NPPs), especially PAs and NPs, can provide E/M services on their own, can bill on time alone, and can do counseling and coordination of care on their own," says Michael A. Ferragamo, MD, FACS, clinical assistant professor, University Hospital, State University of New York, Stony Brook.

Second, it clarifies that "you have to have that counseling with someone who is certified or technically licensed to provide that type of service; it can't be your office administrator, so to speak," Mac explains. "It is just a clarification, and I think it was understood before, but it could have been abused in some way."

Check the Updated Guidelines for More on NPPs

CPT® updates aren't just about code revisions. You also need to pay attention to changes in guidelines.

Case in point: The E/M guidelines will be revised to incorporate new "physician/qualified health care professional" language. For instance, the revised guidelines will state, "A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years."

Don't miss: To help you apply the definitions for new/established patients, the related 2013 guidelines also add this new language: "When advanced practice nurses and physician assistants are working with physicians, they are considered as working in the exact same specialty and exact same subspecialties as the physician."

In other words, the guidelines for determining whether a patient is new or established will state that NPs, APNs, and PAs "are considered the same specialty as the physician with whom they are working/collaborating care as an extender," says Kelly C. Loya, CPC-I, CHC, CPhT, Director of Enterprise Risk, Internal Audit, and Compliance for Sinaiko Healthcare Consulting Inc., a reimbursement services division of Altegra Health.

"This specialty issue has been somewhat 'gray' in the past since nonphysician practitioners are submitted with their own Medicare specialty codes when billed with the nonphysician's NPI number," Loya adds. "It is reassuring that this is now crystal clear."

Hospital Care Takes on Typical Times

In one more change for E/M, CPT® will add typical times to the same-day observation or inpatient admission and discharge codes, 99234-99236 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date ...), says Jodi Good, CPC-I, CCS-P, PCS, Manager of Professional Coding Services for Altegra Health Inc.

Expect to see 40 minutes assigned to 99234, 50 minutes to 99235, and 55 minutes to 99236. Previously, these codes did not have typical times associated with them. The change allows providers to bill based on time when counseling and coordination of care dominate the service, Good explains.