Pediatric Coding Alert

Payment assignments to these codes could signal the way for private payer fees.

CMS offers several bits of good news in its recently-finalized 2013 Medicare Physician Fee Schedule, including new transitional care management codes and associated payment--but the agency also included a 26.5 percent conversion factor cut that could impact practices across-the-board if Congress doesn’t act to reverse it before Jan. 1.

On Nov. 1, CMS released its Final Medicare Physician Fee Schedule for 2013. The 1,362-page document, which was published in the Nov. 16 Federal Register, is applicable to your practice because many private payers base their fees on Medicare reimbursement amounts.

Check These New Codes for Hospital Transitions

If your pediatrician spends a significant amount of time providing care for patients transitioning back to the community following a hospital or nursing facility discharge, you could benefit from two new codes for these services in 2013:

"We will pay for care coordination in the 30 days following an inpatient hospital, outpatient hospital observation services or partial hospitalization, skilled nursing facility (SNF) or CMHC (community mental health center) discharge from the treating physician in the hospital to the beneficiary’s primary physician in the community," CMS says in the document, with the following new codes assigned to the services:

• 99495: 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 face-to-face visit within 14 calendar days of discharge
• 99496: 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 face-to-face visit within seven calendar days of discharge

What’s not included: CMS is quick to note that these new codes are only for face-to-face services, and all payments for non-face-to-face care management should be bundled into your E/M codes.

In addition, the Fee Schedule stresses, the first face-to-face visit is part of the transitional care management (TCM) service and should not be separately reported, although E/M services after the first face-to-face visit may be separately reported. Plus, the physician providing TCM "must have an established relationship with the patient," meaning the physician must have seen the patient within the past three years.

Payment: CMS assigns a work RVU of 2.11 to 99495 ($52.77, using the current 2013 conversion factor) with a typical time of 40 minutes, and a work RVU of 3.05 to 99496 (which amounts to about $76.27 using the current 2013 conversion factor), with an intra-service time of 50 minutes. It will be up to private payers to determine whether they will adopt these payment amounts or assign their own fees to the codes.

More Steep Cuts Will Hit

As many pediatric practices are aware, Congress voted earlier this year to eliminate a 27 percent Medicare payment cut that was supposed to kick in for 2012. Unfortunately, practices will have to play a waiting game once more next year and hope that legislators halt such cuts going forward, because the 2013 Fee Schedule includes a similar reduction, bringing the 2013 conversion factor down to $25.0008.

"In the absence of Congressional action, an overall reduction of 26.5 percent will be imposed in the conversion factor used to calculate payment for physicians’ services on or after January 1, 2013," the Fee Schedule says.

Pediatric boost: Primary care practices will enjoy pay raises that are now reflected under the Fee Schedule. CMS has finalized a three percent raise for pediatricians, a seven percent increase for family practitioners, and a four percent boost for internal medicine physicians. In addition, remember that you’ll also benefit from Medicaid pay changes coming for evaluation and management and immunization administration codes to the equivalent of Medicare payments for 2009 or 2013, whichever is greater, and will be in effect for two years based on the Affordable Care Act. An important aspect of maintaining the pay increase will be showing an improved access to care for Medicaid patients.

You can find a full list of the codes affected by the MPPR in the Final Rule by emailing editor Torrey Kim for a copy (torreyk@codinginstitute.com) for a copy of the document.