Pediatric Coding Alert

Prolonged service confusion, telehealth expansion, and a bottom line increase for 2021.

As usual, this year’s Physician Fee Schedule (PFS) final rule has a lot packed into its 2,165 pages. But ultimately there are four big takeaways for pediatric coding.

Here they are, along with some expert opinion to help you understand how the final rule will impact you in 2021.

Takeaway 1: Add These New HCPCS Codes to Your List

The final rule introduces G2211 (Visit complexity inherent to evaluation and management…), which you can use to “recognize the resources inherent in holistic, patient-centered care that integrates the treatment of illness or injury, management of acute and chronic health conditions, and coordination of specialty care in a collaborative relationship with the clinical care team,” according to the Centers for Medicare & Medicaid Services (CMS).

CMS anticipates that it could be used on up to 90 percent of office/outpatient E/M [evaluation and management] visits, most likely on higher-level office/outpatient E/M visits whenever your pediatrician is “serving as a focal point for the patient’s care … by furnishing care for some or all of the patient’s conditions across a spectrum of diagnoses and organ systems with consistency and continuity over time.”

The final rule also introduces G2212 (Prolonged office or other outpatient evaluation and management service(s) …), which is CMS’ attempt to resolve their prolonged service dispute with CPT^® over when to add a prolonged service code to 99205 (Office or other outpatient visit for the evaluation and management of a new patient … 60-74 minutes of total time is spent on the date of the encounter) or 99215 (Office or other outpatient visit for the evaluation and management of an established patient … 40-54 minutes of total time is spent on the date of the encounter).

CPT^® guidelines tell you to add +99417 (Prolonged office or other outpatient evaluation and management service(s)…) when the service goes one minute beyond either code’s maximum time ranges — 75 minutes in the case of 99205 and 55 minutes for 99215. CMS disagreed with this application of the code in the 2021 proposed rule and argued that you should apply it to the E/M visits when their times hit 15 minutes beyond the maximum time range for 99205 (i.e., 89 minutes) and 99215 (i.e., 69 minutes).

In the final rule, CMS stuck by its interpretation of the guidelines and introduced G2212 to replace +99417. This means you will “have to bill differently for prolonged office visits whenever you bill Medicare or payers that follow Medicare guidelines than you will payers who follow CPT^®, adding more administrative complexity, which is the last thing you need these days,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Takeaway 2: Make the Call on These Telehealth Additions

CMS permanently added nine services to the telehealth list for this year including codes 99347-99348 (Home visit for the evaluation and management of an established patient …) and +96121 (Neurobehavioral status exam …each additional hour) (the add-on code to 96116 [Neurobehavioral status exam … first hour], which was already on the list) along with G2211 and G2212.

Additionally, CMS added a number of E/M codes to the list as temporary, category 3 codes “through the calendar year in which the PHE [public health emergency] for COVID-19 ends,” according to the final rule. These include 99349-99350 (Home visit for the evaluation and management of an established patient …), 99281-99285 (Emergency department visit for the evaluation and management of a patient …), 99238- 99239 (Hospital discharge day management …), 99217 (Observation care discharge day management …), and subsequent inpatient/observation codes 99469 (Subsequent inpatient neonatal critical care, per day … 28 days of age or younger), 99472 (… 29 days through 24 months of age), 99476 (… 2 through 5 years of age), and 99224-99226 (Subsequent observation care, per day …).

CMS has no plans to add any of the corresponding initial inpatient/observation codes (99468, 99471, 99475, or 99221-99223) to the Medicare telehealth list “either permanently or temporarily.”

Takeaway 3: Immunizations Continue Their Fall