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The New Year brings more changes to CPT E/M codes

From the January-February ACP Observer, copyright 2006 by the American College of Physicians.

By Carol McKenzie and Brett Baker

The AMA committee that updates the Current Procedural Terminology (CPT) codes has made several changes to the 2006 edition. Internists will be most affected by changes to the evaluation and management (E/M) service codes.

Here is an overview of important revisions listed by CPT category:

Follow-up inpatient consultations

CPT deleted the established patient follow-up inpatient consultation codes, 99261-99263, because physicians often used them incorrectly and because other existing E/M codes can be used.

  • Use the initial inpatient consultation codes, 99251-99255, to report an initial consultation with a patient in the hospital or a nursing facility. Use an initial inpatient consultation code only once for a particular episode of care.

  • Use the subsequent hospital care codes, 99231-99233—or the new subsequent nursing facility care codes, 99307-99310, which are described below—to report services previously considered to be follow-up consultations. Such consultations would include completing an initial consultation by discussing with the patient test results that weren't previously available.

Physicians benefit financially from these code changes because Medicare will now pay more at each level of service for a subsequent hospital visit.

Confirmatory consultations

CPT deleted the confirmatory consultation codes, 99271-99275, because physicians often used them incorrectly and because other existing E/M codes can be used.

  • Use the office or other outpatient consultation codes, 99241-99245, to report a confirmatory consultation furnished to a new or established patient in the office.

  • Use the initial inpatient consultation codes, 99251-99255, to report a confirmatory consultation furnished to a new or established patient in the hospital.

  • Append modifier -32 when the confirmatory consultation is mandatory, such as one required by a payer.

Again, physicians will do better financially because Medicare will now pay more for office consultations and for initial inpatient consultations respectively at each corresponding level of service.

New language in the CPT introductory text to the consultation code section states that physicians should use the office and other outpatient service codes, 99211-99215, to report patient-initiated "second opinion" consultations. You should not use the consultation codes to report these encounters.

Medicare does pay for patient-initiated second opinions to determine whether patients should undergo surgery or a major non-surgical diagnostic or therapeutic procedure.

Unfortunately, Medicare will now pay less for a patient-initiated second opinion. That's because the Centers for Medicare and Medicaid Services pays less for an office visit than it used to pay for a confirmatory consultation at each corresponding level of service.

Nursing facility services

CPT made substantial revisions to the nursing facility services section to better reflect current practices. Those practices have been influenced by regulations related to convalescent, rehabilitative, long-term or psychiatric care in nursing or residential facilities.

The committee also deleted the "typical time" assigned to the comprehensive and subsequent nursing facility care codes to allow new typical times to be established.

  • CPT deleted the comprehensive nursing facility assessment codes, 99301-99303, and replaced them with initial nursing facility care codes, 99304-99306. The committee established the three initial nursing facility care codes so services could correspond with the three levels of initial hospital care.

  • CPT also deleted the three subsequent nursing facility care codes, 99311-99313, and replaced them with four slightly revised codes, 99307-99310. CPT established the fourth and highest level code—99310—to allow physicians to report a comprehensive level of care. You should use this code for comprehensive history and examination services and for highly complex medical decision-making.

  • And CPT established a new code for a comprehensive nursing facility assessment, 99318, which is in a new subsection entitled "Other Nursing Facility Service." Previously, CPT included codes for both a comprehensive assessment and an admission/readmission in the "Comprehensive Nursing Facility Assessments" subsection.

Domiciliary, rest home or custodial care services

CPT made comprehensive revisions to the domiciliary, rest home or custodial care services section. Those changes acknowledge the growing number of patients with complex diseases who are eligible for this type of care and are increasingly able to stay in these non-medical facilities because of diagnostic and therapeutic advances.

CPT deleted the three new patient domiciliary or rest home codes, 99321-99323, and replaced them with five new codes, 99324-99328. It also deleted the three established patient domiciliary or rest home codes, 99331-99333, and replaced them with four new codes, 99334-99337. CPT increased the number of service levels for both the new and established patient codes to enable physicians to report comprehensive care.

New language in the CPT introductory text to the domiciliary or rest home codes states that physicians should use these codes to report E/M services provided to patients in assisted living facilities.

Home, domiciliary or rest home care plan oversight services

CPT established two new codes to describe physician supervision of a patient—when the patient is not present—who resides in his or her home, a domiciliary or a rest home, including an assisted living facility.

The new codes, 99339-99440, supplement existing CPT codes that describe physician care plan oversight of patients who receive home health care (99374-99375), are enrolled in a hospice (99376-99377) or live in a nursing facility (99379-99380). (The CPT introductory text to these new codes states that physicians should not use them with codes 99374-99380.)

The two new codes describe the same range of services and follow the same guidelines as the CPT care plan oversight service codes, 99374-99380. The new codes, along with the seven in the 99374-99380 series, all describe the following physician work:

  • development and/or revision of care plans;
  • review of subsequent reports of patient status;
  • review of related laboratories and other studies;
  • treatment-related communications with other health care professionals and other decision makers;
  • integration of new information into the treatment plan; and/or
  • adjustment of medical therapy.

Use the new 99339-99400 codes to report care oversight provided to children and adults with special health needs. You should also use these codes when coordinating the medical care management with other medical and non-medical providers for patients with chronic medical conditions.

ACP is in the process of determining whether Medicare will make a separate payment this year for services reported with these two new codes.

Carol McKenzie is Administrative Coordinator for Regulatory and Insurer Affairs in ACP's Washington office. Brett Baker is Director for Regulatory and Insurer Affairs, also in ACP's Washington office.

You can order a copy of "CPT 2006" from the AMA by calling 800-621-8335. It is also available through other vendors. Review the E/M service code and other changes to make sure you are reporting the most recent codes.

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