A New Year and New Billing Opportunities

By Mary Jean Sage

A new year means new billing codes, new Medicare regulations and guidelines and new revenue opportunities for medical practices. To make the most of these opportunities, make sure you implement changes early in this New Year. There are very few coding changes and only a few Medicare changes this year, but all are important and worth reviewing to ensure you use them effectively.

Current Procedural Technology (CPT) Changes    

Evaluation and Management (E/M) are services that all family physicians provide to patients on a regular basis. While there are no new E/M service codes this year that provide any challenges for family physicians, there are a couple of new guidelines that should be reviewed.

New versus Established Patients

There is a definition revision in CPT for 2012 that helps distinguish new and established patients. Solely for the purposes of distinguishing new and established patients, professional services are face-to-face services rendered by a physician and reported by a specific CPT code. 

A new patient is one who has not received any professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

An established patient is one who has received professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years. 

There are two parts to this definition that are important for medical practices. 

1) The first is “professional services.”  Picture a scenario where you have not seen a patient for a period of five years, but two years ago that patient telephoned you with minor “flu-like” symptoms and you advised rest, fluids, over-the-counter medications and a visit to your office if there was no improvement within a few days. The patient did not come to the office for a visit at that time.  Now the patient is coming in for a visit with a new problem.   Even though you have communicated with the patient within the last three years, there was no face-to-face service with the patient.  Therefore, the current visit will be considered a new patient visit once again. 

2) The second is “specialty” and “subspecialty.”   Drs. Green and Blue are in the same family practice.  Dr. Blue is boarded in Geriatric Medicine and practices that exclusively.  Payers have classified Dr. Blue in that subspecialty. Dr. Green, who is not boarded in Geriatric Medicine and is not recognized by payers in that subspecialty, refers an 85-year-old patient to Dr. Blue for consideration of some cognitive function issues. This would be considered a new patient service for Dr. Blue because the subspecialty is not exactly the same, the payer recognizes the subspecialty and the physician has the designation in a distinct subspecialty board. 

Initial Observation Care

In 2011, CPT codes were established for subsequent observation care and those codes were assigned times that mirrored the typical times of subsequent inpatient hospital visits. In 2012 typical times are established for the three Initial Observation Care codes (99218, 99219 and 99220). Those typical times are a crosswalk to the typical times for initial hospital care. 

The work relative value unit (RVU) is increased slightly for these three services and the observation setting has been added to the list of appropriate services for use with inpatient prolonged service codes.

Prolonged Services:

The physician-specific references are removed from the title of these services and “other qualified health care professionals” is added. Additionally, the “face-to-face” reference is removed and “direct patient contact” is defined. In the inpatient environment, floor and unit time is considered to be direct patient contact by CPT guidelines.

Immunization Administration for Vaccines/Toxoids

There are no new administration codes, but there are some explanatory statements added to the guidelines for using the administration codes.   The guidelines clarify that conjugates and adjuvants are not be to considered a component of a vaccine when reporting codes 90460 and 90461. Multivalent antigens or multiple serotypes of antigens against a single organism are considered a single component of a vaccine. For example, Pneumococcal Vaccine has up to 23 antigens, but is a single disease vaccine (not a combination vaccine) and influenza has multiple sub-types, but also is a single disease vaccine. 

There is a change to the introduction of CPT under the subheading of “Instructions for Use of CPT Codebook” that is important to the use of these two administration codes. That instruction, which is at the very beginning of the CPT book, defines a “physician or other qualified health care professional” as an individual who is qualified by education, training, licensure/regulation (when applicable) and facility privileging (when applicable) who performs a professional service within his or her scope of practice and independently reports that service. It goes on to distinguish these professionals from “clinical staff.”  A clinical staff member is a person who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specified professional service, but who does not individually report that professional service. 

The clarification is in response to questions that have arisen regarding who can do the counseling as part of the 90460 and 90461 vaccine administration service. There is now clarity that health care professionals are distinct from clinical staff and it should be a physician, nurse practitioner, clinical nurse specialist or physician assistant who provides counseling at the time of administration of the vaccine(s).  Registered nurses and medical assistants are considering clinical staff and should not provide this counseling for 90460 and 90461 services. 

CPT 90470 (H1N1) immunization administration has been deleted. CPT 90663 (influenza virus vaccine, pandemic formulation, H1N1) immunization has also been deleted.

There are other CPT changes throughout the whole spectrum of CPT codes that physicians should review but many of them are not typically provided in a family practice setting. If you do things such as ultrasound guidance for any procedures, or if you do an unna boot and/or multilayer compression system application, then you will want to review the changes for these services. There are also some guideline changes for integumentary debridement and repair (closure) guidelines that practices should review if relevant. 

Medicare in 2012

Deductible

The Medicare deductible for 2012 is $140 per patient. Since Congress approved legislation late in 2011 that temporarily blocked the Medicare payment reduction and extended the 2011 Medicare payment rates for roughly two months, every practice should begin collecting the deductible and coinsurance amounts from Medicare patients based on the 2011 Medicare Fee Schedule amounts. 

Medicare Benefits for Patients:

The Annual Wellness Visit (AWV) is further defined and the work value of this service is increased, providing a slight fee increase. This service, as defined in Section 1861 (hhh)(1)(A) of the Affordable Care Act (ACA), requires a Health Risk Assessment. This Risk Assessment is now defined to include:  self-reported information that can be done by patient; takes no more than 20 minutes to complete; addresses demographic data; psychosocial risks; behavioral risks; and ADLs. If you are providing this service to your Medicare patients – and every family practice should be – make sure your documentation supports that you are doing the assessments as defined in the regulation. 

Telehealth Services are expanded. The services for smoking cessation have been added to the list of covered telehealth services:

• For symptomatic patients
• 99406 – smoking cessation (three to 10 minutes)
• 99407 – smoking cessation (more than 10 minutes)
• For asymptomatic patients
• G0436 – smoking cessation (three to 10 minutes)
• G0437 – smoking cessation (more than 10 minutes)

New Coverage Decisions were made in the last quarter of 2011 and we are awaiting specific instructions from the CMS on reporting and billing for these services.  These services include:

• Screening and counseling for obesity
• Expansion of coverage for cardiovascular disease prevention
• Screening and counseling for alcohol misuse
• Screening for depression

There are HCPCS Level II codes (G codes) established for these services, but CMS has not yet issued coverage or payment guidelines for reporting these services.  Stay informed by checking the Palmetto, the CA Medicare Advisory Committee (MAC) website as well as the American Academy of Family Physicians’ blog.

Other Medicare Issues:

• Revalidation of Provider Enrollment Records continues, although the completion date is extended to 2015 instead of the original 2013 date. Physicians and providers who enrolled in Medicare before March 25, 2011 will eventually have to go through this re-validation process. CMS is selecting providers for the contractors and the ones first in line are those in the Medicare payment system, but not in the Provider Enrollment Chain and Ownership System (PECOS). Your office staff should be watching for these re-validation notices. They will arrive in a large yellow envelope and physicians have 60 days from the date on the letter to complete the re-validation process.  CMS is promising to update and make the PECOS system simpler and easier to use in an effort to encourage more physicians and suppliers to use this system to do the re-validation. 

• A new ABN Form must be used as of January 1, 2012. The form is virtually the same form that has been used for the past several years (Form CMS-R-131), but has a new effective date in the lower left-hand corner of the form (03/11).  Make sure your office is using the correct form when you ask a Medicare patient to sign an Advance Beneficiary Notice of Noncoverage (ABN) for any service you believe will not be covered because of a medical necessity issue. Click here for a copy of the new form.

• The last update of ICD-9 was implemented on October 1, 2011 and the diagnoses codes will be used through September 30, 2013 until ICD-10 becomes effective on October 1, 2013. For a summary of the changes implemented on October 1, 2011 review the article in the November/December 2011 issue of Family Practice Management. It may be premature to begin researching diagnoses and transitioning your most used diagnoses to ICD-10 because they cannot be used until October 2013, but it is time to begin planning to assure that all systems, processes and personnel are properly prepared and available to handle the ICD-10 transition. Watch for a future CAFP Practice Management News article that will help you plan for this transition.

Ensure that your practice is doing everything possible to maximize payment for the services you provide in 2012.

Mary Jean Sage has extensive experience in the health care field spanning a period of more than 20 years during which time she has managed diverse groups of professionals in delivering patient care.  A founding Principal and Senior Consultant with The Sage Associates, Mary Jean is a nationally-known speaker, consultant and educator. 

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