Pulmonology Coding Alert

Think you have all the answers? Find out.

How well do you remember these major coding changes from 2021?

After you’ve answered the quiz questions on page 3, see if your answers match up with the ones provided below.

How Long Will Category 3 Telehealth Services Coverage Remain?

Answer 1: The CY 2021 MPFS final rule created Category 3 to the Medicare telehealth services list to add services temporarily following the end of the COVID-19 PHE. The added services offer a clinical benefit when furnished via telehealth, even though there isn’t enough evidence for the services to make permanent additions to Category 1 or 2.

In the proposed rule earlier in 2021, CMS proposed retaining services added to the Medicare telehealth services list on a Category 3 basis until the end of CY 2023. CMS mentioned the retention of services allows more time to gather additional information “regarding utilization of these services during the pandemic,” as well as providing stakeholders with ample time to build support for the permanent addition of appropriate services.

CMS finalized their proposed revised timeframe for including services added to the Medicare telehealth services list. Additionally, CMS is permanently recognizing and reimbursing for longer virtual check-in services. “These services are valuable to patients who require frequent evaluations (e.g., every 2 months), but don’t necessarily need those evaluations to be in-person (e.g., patients with controlled conditions without exacerbation),” says Carol Pohlig, BSN, RN, CPC and Manager, Coding & Education in the Department of Medicine at the Hospital of the University of Pennsylvania in Philadelphia. The virtual check-in visits are also helpful following medication changes to see if the patient’s condition is improving and if the medication is effective.

Specify Cough Severity with Expanded Codes

Answer 2: In the 2022 ICD-10-CM code set, R05.- (Cough) has been converted to a parent code to offer greater specificity for the patient’s condition. Under the new parent code, which features a 4th character required icon, you’ll find six new expanded codes, which include:

• R05.1 (Acute cough)
• R05.2 (Subacute cough)
• R05.3 (Chronic cough)
• R05.4 (Cough syncope)
• R05.8 (Other specified cough)
• R05.9 (Cough, unspecified)

The expanded codes offer three levels of severity, from acute through subacute to chronic, the last of which also has three synonyms: persistent cough, refractory cough, and unexplained cough. Additionally, you will be able to use R05.4 to document cough syncope, a condition where a patient loses consciousness after a coughing bout.

Code first note: Code R05.4 carries a Code first note that instructs you to assign R55 (Syncope and collapse) before R05.4.

See if You Recall Who Provides Principal Care Management

Answer 3: CPT^® introduced a new family of principal care management (PCM) codes that take effect January 1, 2022. The new PCM codes include:

• 99424 (Principal care management services, for a single high-risk disease, with the following required elements: one complex chronic condition expected to last at least 3 months, and that places the patient at significant risk of hospitalization, acute exacerbation/decompensation, functional decline, or death, the condition requires development, monitoring, or revision of disease-specific care plan, the condition requires frequent adjustments in the medication regimen and/or the management of the condition is unusually complex due to comorbidities, ongoing communication and care coordination between relevant practitioners furnishing care; first 30 minutes provided personally by a physician or other qualified health care professional, per calendar month.)
• +99425 (…; each additional 30 minutes provided personally by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure)
• 99426 (…; first 30 minutes of clinical staff time directed by physician or other qualified health care professional, per calendar month.)
• +99427 (…; each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure)

Going forward, providers who care for patients with a single chronic condition will now receive payment for their services. Starting in 2022, reimbursement is available “for care management of patients with a single chronic condition, whereas previously such services were reimbursed only for patients with multiple chronic conditions,” says Nick Hut, Senior Editor of Healthcare Financial Management Association in a blog post (URL: www.hfma.org/topics/revenue-cycle/article/ama-releases-2022-cpt-code-set-with-new-options-that-apply-to-co.html).

Additionally, specialists, such as pulmonologists, aren’t required to take on the complete care of a patient for unrelated diagnoses and they can use the PCM codes to receive reimbursement. By introducing the PCM services, CMS’s aim is to help improve care for patients with complicated conditions while keeping them out of the hospital and emergency room.

One problem with the new CPT^® codes is that they align with CMS-recognized HCPCS codes G2064-G2065 (Comprehensive care management…), which are already established.

Will CMS adopt the usage of 99424-99427 or stick with the G-codes? “It’s unclear,” Pohlig says. “Practices that currently report PCM services under the G-codes, would continue to report these services, and may be able to expand these services to private payers.”