Pediatric Coding Alert

Plus: You’ll find new code for infant hypothermia inducement.

Although 2015 might sound rather far away, the fact is that January will soon be creeping up on us—and with the new year come new CPT® codes to keep your pediatric practice billing accurately. Although the American Medical Association just released the new codes, we’ve got a sneak peek at the ones that will impact you the most.

CCM Already Updated

You might just be getting to know the complex chronic care coordination code 99487, which CPT® introduced in 2013, but it’s already getting a facelift. CPT® has changed the title to complex chronic care management, deleted one add-on code in the series, and also debuted several companion codes. The following changes will be relevant to any pediatrician who manages patients with chronic problems:

Revised (the changes are emphasized below)

You’ll note that 99488 (…first hour of clinical staff time directed by a physician or other qualified health care professional with one face-to-face visit, per calendar month) has been deleted completely, and 99489 (...each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month) is the same as it was in the past. 

The updates reflect the stringent requirements that you must meet to bill these codes. Now the descriptor clearly states what is required, such as the fact that the patient must have at least two chronic conditions that won’t resolve within the next year or more (or until the patient passes). In addition, the conditions must put the patient at high risk, and the pediatrician or other clinician must spend at least 60 minutes per month directing the chronic care management.

The deletion of 99488 makes sense since the service it described would now be included in the new description of 99487. In addition, CPT® debuted the following new codes to join this category.

New:

Interestingly, these new codes offer the ability to capture clinical staff members’ work taking care of chronic care management services. For instance, if the pediatrician directs the nurse to monitor the plan of care of a premature infant with feeding and persisting respiratory problems for 20 minutes a month, this code would allow for the nurse to bill for that non-face-to-face work. It would be a welcome change if payers reimburse this important series of codes supporting the work of providing a medical home for children with special care needs.

Check Out These Vaccine Changes

Also appearing in CPT® 2015 will be dozens of new and revised vaccine codes, including the following additions to flu and HPV immunizations:

New codes:

You’ll also find the following revisions that could make a difference when you code your flu shots and well child immunizations:

Revisions:

Hypothermia Initiation Code Debuts

Pediatricians who treat critically ill infants will benefit from a new code that describes the doctor’s work inducing a hypothermic state. Note that this code does not refer to a pediatrician’s treatment of naturally occurring hypothermia. Instead, the descriptor implies that pediatricians will report 99184 (Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling) when they induce a controlled hypothermic state to help the patient stabilize other systems.

A Helpful Code for Application of Fluoride Varnish

If you are providing the evidence-based application of topical fluoride varnish for your patients, you’ll benefit from the new code 99188 (Application of topical fluoride varnish by a physician or other qualified health care professional). Report this when the pediatrician gives the patient a fluoride varnish application. This could be administered by your nurse as an incident to service. Provision of dental services in the pediatric office is growing more common, particularly with Medicaid mandated dental reviews when in-depth dentist’s services are not required.

Keep in mind: Until the annual publication of the CPT® code set, small further revisions may occur to the 2015 codes. Keep an eye on Pediatric Coding Alert for additional news on the new codes.

Take in New Modifier Possibilities

In addition, CMS introduced four new modifiers to take the place of modifier 59 in specific circumstances. If private payers and Medicaid insurers adopt the same regulations as Medicare payers seem poised to do, these could affect your pediatric practice. 

CMS describes modifier 59 as “the most widely used HCPCS modifier,” and intends to stop that by introducing four modifiers to take its place in specific circumstances.

As most coders are aware, modifier 59 (Distinct procedural service) can separate CCI edits, but it is not meant to be utilized solely for that reason. In fact, CMS says in Transmittal R1422 (issued on Aug. 15) that many providers misuse it for this purpose, leading the modifier to be the source of a projected one-year error rate of $770 million. 

CMS points out the following three common reasons that people use modifier 59, along with the associated error odds, according to MLN Matters article MM8863, issued on Aug. 15:

• Infrequently used to identify a separate encounter, typically used correctly
• Less commonly utilized to define a separate anatomic site, less often used correctly
• Commonly used to define a distinct service, but frequently done so incorrectly

Say Hello to “EPSU” Modifiers

In light of the problems that CMS has faced when dealing with modifier 59, the agency felt the need to find a solution. “The 59 modifier often overrides the edit in the exact circumstance for which CMS created it in the first place,” the MLN Matters article says. “CMS believes that more precise coding options coupled with increased education and selective editing is needed to reduce the errors associated with this overpayment.” 

To that end, CMS has debuted the following new modifiers, known as the “X(EPSU)” modifiers:

• XE: Separate encounter (A service that is distinct because it occurred during a separate encounter)
• XS: Separate structure (A service that is distinct because it was performed on a separate organ/structure)
• XP: Separate practitioner (A service that is distinct because it was performed by a different practitioner)
• XU: Unusual non-overlapping service (The use of a service that is distinct because it does not overlap usual components of the main service)

Although the new modifiers will replace modifier 59 in specific instances, CMS won’t cease accepting -59 in 2015. “CMS will not stop recognizing the 59 modifier but notes that CPT® instructions state that the 59 modifier should not be used when a more descriptive modifier is available,” says the Transmittal, which has an effective date of Jan. 1, 2015. “CMS will continue to recognize the 59 modifier in many instances but may selectively require a more specific X(EPSU) modifier for billing certain codes at high risk for incorrect billing.”

Keep in mind that CMS does not want you to play it safe and just add all of the modifiers to each CCI edit you’re trying to separate. Therefore, you can’t report both the 59 modifier and an X(EPSU) modifier on the same line item. 

Resource: To read the transmittal, visit www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1422OTN.pdf. To read the MLN Matter article, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8863.pdf.