Pediatric Coding Alert

Some payers are reimbursing 99415-99416, while others have balked.

When CPT^® 2016 took effect on Jan. 1, many coders cheered over the addition of two new prolonged service E/M codes that enable you to capture nonphysician work that staffers perform after the physician sees the patient for an E/M service. On the flip side, however, many practices are in the dark over whether these codes are payable. Pediatric Coding Alert pored over various payer policies to find out just when you can collect for these services, and when you may be out of luck.

Know What the New Codes Encompass

Starting Jan. 1, 2016, you’ve been able to report 99415 (Prolonged clinical staff service [the service beyond the typical service time] during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour [List separately in addition to code for outpatient Evaluation and Management service]) and 99416 (…each additional 30 minutes [List separately in addition to code for prolonged services]), when appropriate to the encounter.

These codes debuted to demonstrate the clinical staff members’ time during an E/M service, because often, a physician’s time with the patient only paints a partial picture of what occurred during the visit. For example, staff might give the patient an injection, provide education for a new medication or therapy, or provide guidance or service that goes far past the time associated with the E/M code. The new codes offer coders a way to recognize that nonphysician work.

Know the Coding Rules

In its “Direct Prolonged Services: Inpatient/Outpatient Coding” fact sheet, the American Academy of Pediatrics advises practices that the physician or other qualified health care professional must be present to directly supervise the clinical staff member, and that you cannot report 99415 unless the staff member has spent “a minimum of 45 minutes beyond the typical time of the E/M service code being reported.” In such cases, you’ll report the appropriate E/M code that the pediatrician documents, followed by the add-on code for the clinical staff’s prolonged service.

Example: A seven-year-old patient with a history of hymenoptera allergy presents with a bee sting. The physician examines the patient and determines that the child has an increased heart rate and swelling around the sting site. He orders an epinephrine shot and asks the clinical staff member to sit with the patient to ensure that the medication takes effect and the patient’s symptoms do not worsen. The doctor reports 99213 and spends 15 minutes with the patient. The total time that the nurse spends is 50 minutes. You can therefore report 99213 and one unit of 99415. The clinical staff has to document what they did during that 50 minutes. For instance, “Monitored the patient’s heart rate, blood pressure and respiratory rate frequently, as well as evaluating any reactions for total amount of time of 50 minutes.”

Nail Down Payments

The Medicare Physician Fee Schedule did apply reimbursement values to 99415 (which pays about $9.00) and 99416 (which pays about $5.00) effective January 1. Although this is usually a good indicator of what private payers will do, some insurers are already balking at paying practices for these new codes.

Harvard Pilgrim Health Care says that these codes are not reimbursable, as does the Connecticut Medical Assistance Program. United Health Care, however, appears to cover the services as long as you adhere to the policy dictating that they must be billed as an add-on code to an appropriate E/M service.

AmeriHealth’s policy notes that 99415 should be used “only once per date to report the first 30-60 minutes of prolonged face-to-face services,” whereas it dictates that 99416 “is used to report each additional 30 minutes beyond the first hour of the final 15-30 minutes of prolonged face-to-face physician services on
a given date.”

Many other payers, such as Cigna and Aetna, had not published their 99415-99416 policies as of press time. In these situations, you should contact the insurer directly and ask for a copy of the reimbursement policy for these new codes. In the meantime, continue to ensure that your documentation demonstrates the exact amount of time that both the doctor and the clinical staff member spends during the visit, as well as what constituted the visit.