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1999 CPT codes feature new E/M guidelines, modifiers

From the January 1999 ACP-ASIM Observer, copyright © 1999 by the American College of Physicians-American Society of Internal Medicine.

By Brett Baker

Q: What changes have been made to the evaluation and management (E/M) services guidelines in the 1999 current procedural terminology (CPT)?

A: Two paragraphs have been added to the "Levels of E/M Services" heading under the "Definition of Commonly Used Terms" section of the E/M guidelines, which prefaces the section containing the actual E/M codes. Each new paragraph, followed by an explanation as to why it was added, is listed below:

Any specifically identifiable procedure (i.e., identified with a specific CPT code) performed on or subsequent to the date of initial or subsequent E/M services should be reported separately.

This paragraph was added to clarify that it is appropriate to report a procedure that can be identified by a CPT code when done in conjunction with an E/M service.

The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond other services provided or beyond the usual preservice and postservice care associated with the procedure performed. The E/M service may be caused or prompted by symptoms or conditions for which the procedure or service was provided. This circumstance may be reported by adding the modifier -25 to the appropriate level of E/M service. As such, different diagnoses are not required for reporting of the procedure and the E/M services on the same date.

This paragraph was added to reinforce that it is appropriate to report a separately identifiable E/M service that is performed on the same day as a procedure or service. It clarifies that you can report both a service and a procedure/service on the same day regardless of whether the diagnosis(es) used to justify the service are identical, similar or different than the diagnosis(es) used to support the procedure/service.

The addition of this paragraph is important, as some insurers have refused to pay for a service provided on the same day as a procedure/service unless the diagnosis(es) used to justify the service is distinctly different from the diagnosis(es) supporting the procedure/service. (See below for more information on modifier -25.)

Q: Are there any noteworthy changes to the actual E/M codes?

A: A parenthetical note was added to the end of each prolonged service code descriptor. These revisions are intended to clarify that the prolonged service codes are used in addition to other E/M services. The parenthetical notes vary depending on whether the service involves direct (face-to-face) patient contact or occurs without direct (face-to-face) contact; is for outpatient or inpatient use; or is used for the first hour of service or for each additional 30 minutes.

Here are the revised codes, with the new text in italics:

  • Prolonged physician service with direct (face-to-face) patient contact

    99354—Prolonged physician service in the office or outpatient setting requiring direct (face-to-face) patient contact beyond the usual service (e.g., prolonged care and treatment of acute asthmatic patient in an outpatient setting); first hour. (List separately in addition to code for office or other outpatient E/M service.)

    (Use 99354 in conjunction with codes 99201-99215, 99241-99245, 99301-99350.)

    99355—Each additional 30 minutes. (List separately in addition to code for prolonged service.)

    (Use 99355 in conjunction with code 99354.)

    99356—Prolonged physician service in the inpatient setting, requiring direct (face-to-face) patient contact beyond the usual service (e.g., maternal fetal monitoring for high risk delivery or the physiological monitoring and prolonged care of an acutely ill patient); first hour. (List separately in addition to code for inpatient E/M service.)

    (Use 99356 in conjunction with codes 99221-99233, 99251-99255, 99261-99263.)

  • Prolonged physician service without direct (face-to-face) patient contact

    99358—Prolonged E/M service before and/or after direct (face-to-face) patient care (e.g., review of extensive records and tests, communication with other professionals and/or patient/family); first hour. (List separately in addition to code(s) for other physician service(s) and other inpatient or outpatient E/M service.)

    99359—each additional 30 minutes. (List separately in addition to code for prolonged physician service.)

    (Use 99359 in conjunction with code 99358.)

    Medicare does not pay separately for the above two services as it considers them to be "bundled" into payments for other services. ACP-ASIM encourages members to document these services in the patient's medical record and to consider them when determining the level of service to bill for the patient's next face-to-face visit.

    Also, the following paragraph was added to the introductory text under the "Preventive Medicine Services" heading:

    The "comprehensive" examination of the Preventive Medicine Services codes 99381-99397 is NOT synonymous with the "comprehensive" examination required in the E/M codes 99201-99350.

    The revision is intended to eliminate confusion regarding the definition of the "comprehensive" examination referenced in the introductory notes. Preventive services represent comprehensive examinations for recommended physician intervention standard sets, like those published by preventive medicine agencies, such as the American Academy of Pediatrics. They are not synonymous with the comprehensive examination outlined in the remainder of the E/M service codes.

Q: What changes have been made to the modifiers used with E/M codes?

A: CPT modifiers were moved from the "guidelines" section that prefaces each section of CPT codes (i.e., E/M guidelines, surgery guidelines, pathology and laboratory guidelines, etc.), and are now in a single list, which is contained under appendix A in "CPT 1999."

In addition, modifier -25, which was listed in the E/M guidelines section of CPT 1998, was revised to read as follows (new text is in italics):

-25 Significant, Separately Identifiable E/M Service by the Same Physician on the Same Day of the Procedure or Other Service: The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M service on the same date. This circumstance may be reported by adding the modifier -25 to the appropriate level of E/M service, or the separate five digit modifier 09925 may be used. Note: This modifier may not be used to report an E/M service that resulted from a decision to perform surgery. See modifier -57.

The text added to the description of modifier -25 is nearly identical to the language added to the E/M guidelines. This ensures that the guidelines are consistent with the modifier and aims to further clarify that a separately identifiable service performed on the same day as a procedure/service is reportable regardless of the diagnosis(es) used to each service/procedure.

"CPT 1999" contains other revisions, including changes to codes in the pathology and laboratory and the medicine sections. The soft-cover standard edition of "CPT 1999" is available from the AMA and costs $35.95 for AMA members and $47.95 for nonmembers. To order a copy, call the AMA at 800-621-8335.

Brett Baker is a third-party payment specialist in the College's Washington Office. If you have questions on third-party payment or coding issues, call him at 202-261-4533, send a fax to 202-835-0441 or send an e-mail to bbaker@acponline.org.


Need help with coding, payment issues?

The following resources are available from ACP-ASIM's Center for a Competitive Advantage:

  • What Internists Should Know About Medicare Changes for 1999. A question-and-answer guide analyzing changes affecting reimbursement for services—including the transition to resource-based practice expenses—and other Medicare policy affecting internists. College members get one copy for free.
  • 1999 Commonly Used ICD-9 Codes. A two-sided laminated sheet listing the International Classification, Ninth Edition (ICD-9) codes most commonly used by internists. Codes are arranged in alphabetical order within disease category. Sheets can be placed in each exam room for quick reference. Members get one copy for free; four copies cost $12.
  • ACP-ASIM's Pocket Reference to Documentation Guidelines for General Multi-System Examinations. A four-fold laminated card that helps internists document their evaluation and management (E/M) services according to Medicare's 1997 documentation guidelines. Members get one copy for free; four copies cost $12.
  • E/M Service Codes: Selecting Levels of Service. An updated three-fold laminated card that helps internists select the appropriate level of evaluation and management (E/M) service. It lists the type of history, exam and decision-making for each E/M code. Members get one copy for free; four copies cost $12.
  • Medicare: What It Will and Will Not Pay For, 1999 edition. A packet containing educational information for internists to distribute to their patients. A master set that can be photocopied costs $30. To order copies, call ACP-ASIM Customer Service at 800-523-1546, ext. 2600, or 215-351-2600 (9 a.m. to 5 p.m. EST). The text of the free publications is also available on the College's Web site (www.acponline.org).

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