New submodifiers for Modifier 59: Do they affect your testing codes?
Beginning Jan. 1, 2015, the Centers for Medicare and Medicaid Services (CMS) instituted a new subset of code modifiers. Modifiers allow a psychologist to indicate to a payer that there is something unusual about the way in which a particular service was provided.
The new submodifiers are: XE (separate encounter), XP (separate practitioner), XS (separate structure) and XU (unusual non-overlapping service). The new modifiers are for use only in the Medicare program.
According to CMS, the correct use of modifier 59 is: “Modifier 59 is used appropriately for two services described by timed codes provided during the same encounter only when they are performed sequentially. There is an appropriate use for modifier 59 that is applicable only to codes for which the unit of service is a measure of time (e.g., per 15 minutes, per hour). If two timed services are provided in time periods that are separate and distinct and not interspersed with each other (i.e., one service is completed before the subsequent service begins), modifier 59 may be used to identify the services.”
The new submodifiers should not be used with the psychological and neuropsychological testing code combinations 96101 with 96102, or 96118 with 96119. For psychological and neuropsychological testing, modifier 59 (separate and distinct service) remains the most appropriate choice when billing the testing code combinations 96101 with 96102, or 96118 with 96119.
Here are the modifiers, with brief explanations of why they are not appropriate for the psychological and neuropsychological testing codes:
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XE (separate encounter) applies when distinct services are provided during different encounters on the same date. In technician-administered testing, the additional time for integration of data from external sources is not a patient encounter.
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XP (separate practitioner) applies when different practitioners deliver the same service during an encounter. In 96102 and 96119, the technician is not the practitioner; the psychologist/neuropsychologist is the practitioner and the one whose name is on the claim.
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XS (separate structure) applies to procedures on different anatomic structures. This is not applicable to psychology/neuropsychology.
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XU (unusual non-overlapping service) applies when a service is distinct because it does not overlap — in an expected way — with the usual components of the main service.
Official CPT coding instruction (in the parenthetical statement that follows each of these code pairs) states that it is permissible to report 96101 with 96102, or 96118 with 96119. Providers should be careful to append modifier 59 to one of the reported codes. Coding guidance for Modifier 59 and its submodifiers (PDF, 131KB) is available from CMS. In this online document, CMS provides a number of examples of correct and incorrect uses of 59, and then follows with examples for the new X [EPSU] modifiers.
Developmental screenings and brief behavioral assessments: CPT changes
CPT code 96110: Developmental screening
CPT code 96110, Developmental screening, was revised to provide a clearer description of this particular service and to distinguish it from the new brief behavioral assessment code and the adjacent psychological and neuropsychological testing codes in the “Central Nervous System Assessments/Tests” section of the 2015 CPT code manual.
The 2015 descriptor for CPT code 96110 now reads: “Developmental screening (eg, developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument.” The italicized passage shows the newly revised language. The phrase “interpretation and report” (present until the end of 2014) was deleted, since the code’s payment value had never included the psychologist’s or physician’s professional work.
CPT 96110 should be used to report screening for healthy, physical development (speech and language development, physical growth).
CPT code 96127: Brief behavioral assessment
Code 96127: Brief emotional/behavioral assessment (for example, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument, is new for 2015.
This code should be used to report a brief assessment for ADHD, depression, suicidal risk, anxiety, substance abuse, eating disorders, etc. This code was created in response to the Affordable Care Act’s federal mandate to include mental health services as part of the essential benefits that must be included in all insurance plans offered in individual and small group markets. The mandate covers services such as depression screening for adults and adolescents, alcohol misuse in adults, alcohol and drug use in adolescents, and behavioral assessments in children and adolescents.
CODING & DOCUMENTATION Tips for Primary Care Physcian
Q List the chief diagnosis code first
I recently saw a patient for a complete physical. She complained of pain in the joints of her hands and bursitis in her hip. Which diagnosis code should I list first? Does it have to be V70.0, “Routine general medical examination at a health care facility”?
A
The guidelines for ICD-9 coding state: “List first the ICD-9-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions.” You must determine which condition was chiefly responsible for the services you provided and list this diagnosis code first. List the additional diagnoses, linking each to the related CPT code. In your example, you should link V70.0 to the preventive medicine services, and link the diagnosis codes for hand pain and bursitis to the problem-oriented evaluation and management (E/M) code, if the work was significant to warrant billing separately for it.
Q Consultation or subsequent care in hospital rehab unit?
A rehabilitation physician has requested my consultation for management of problems such as hypertension and diabetes. His patients are in the acute rehab unit of the hospital and have no other primary care physician. He is recognized as the attending. How should I code these patient encounters?
A
If the hospital bills rehab unit services as inpatient care, then your services are inpatient care. If the hospital bills them as nursing facility care, then your services are nursing facility care.
To bill a consultation, the rehab physician must have requested your advice or opinion on the management of the patient rather than asking you to assume management of the patient’s care.
For inpatient consultations, including those in a nursing facility, see codes 99251–99255. For inpatient care other than consultations or follow-up consultations, see the subsequent hospital care codes (99231–99233). For subsequent nursing facility care other than consultations or follow-up consultations, see the subsequent nursing facility care codes (99307–99310).
Q New vs. established patients
I am a third-year family medicine resident who will be starting work at an established clinic. I will be the only doctor in this clinic. Currently there is a part-time internist working there, but he will leave when I arrive. Can I bill everyone I see as a “new patient” because they are all new to me?
A
In a group practice in which physicians’ services are billed under one tax identification number, a patient is new if no physician of the same specialty has had a face-to-face encounter with the patient in the past three years. According to this definition, which is from Medicare’s Documentation Guidelines for Evaluation and Management Services, the patients are new to you – assuming the internist has been the only physician in the group for the last three years. Keep in mind that some payers may not differentiate between the primary care specialties when determining new versus established, so you should check with the health plans you contract with to determine whether it’s worth the trouble to make the distinction. Only two out of three key components are required for coding established patient visits whereas all three – history, exam and decision making – are needed for new patient visits. Some patients may not understand being designated as “new” patient and having to pay a higher fee, so be prepared to explain the policy.
Q Acupuncture
I am considering incorporating acupuncture into my practice. How should I code these services, particularly for Medicare or Medicaid patients?
A
Medicare does not cover acupuncture, and few state Medicaid programs cover it. You would need to check with your state Medicaid program to be sure of coverage for your services. Medicare beneficiaries may ask you to file a claim to Medicare because the rejection may allow them to file the claim with another insurance company. Because Medicare never covers the service, you do not need to obtain an advance beneficiary notice; however, you may want to obtain a Notice of Exclusion From Medicare Benefits (NEMB) for your records. The NEMB form can be found online at http://www.cms.hhs.gov/BNI/Downloads/CMS20007English.pdf. The acupuncture codes are 97810–97814 and are reported based on 15-minute increments of face-to-face time with the patient.
Q Psychotherapy
What is the correct code for a 90-minute psychotherapy session?
A
You should bill 90808 for 90 minutes of psychotherapy alone, or 90809 if E/M services are included, with modifier -22 appended to your CPT code. You could use the narrative field of your claim form to report the time. Modifiers -22 (unusual procedural services) and -52 (reduced services) may be used to report psychotherapy time that falls outside the times stated in the psychotherapy codes 90804–90809.
Q Managing home INR draws
We have many patients in our practice who monitor their prothrombin time/international normalized ratios (INR) levels at home. We track these results by phone and make dosage changes as needed. Can we bill for this?
A
I would recommend contacting your payers to find out. For Medicare patients with mechanical heart valves, the answer is yes. In such cases, Medicare allows physicians to bill G0250 for review and interpretation of the INR results from home: “Physician review, interpretation and patient management of home INR testing for a patient with mechanical heart valve(s) who meets other coverage criteria; per four tests (does not require face-to-face service).” For the initial demonstration or provision of test materials, see codes G0248 and G0249. To familiarize yourself with the Medicare regulations for billing home INR-related services, see http://new.cms.hhs.gov/transmittals/downloads/ab02180.pdf.
Q E/M + trigger point injections
Can I bill an E/M code with a trigger point injection? Do I need modifier -25 and a separate diagnosis code? Can I bill the Kenalog as well?
A
You can bill an E/M code with a trigger point injection if the E/M service is significant and separately identifiable from the normal pre-service work associated with the injections. This would require modifier -25 but not necessarily a different diagnosis code. The Kenalog would be billed with HCPCS code J3301 (for both Kenalog-10 and Kenalog-40).
Q Swing bed stays
What are the rules for coding swing bed stays after acute care stays in the hospital?
A
Swing bed stays are generally nursing facility services. From a CPT perspective, nursing facility admission codes (99304–99306) include all services on the date of admission except hospital discharge or observation discharge services (99238, 99239, 99217 or 99234–99236). Codes 99307–99310 are used to report subsequent nursing facility care. Note that Medicare allows the billing of inpatient discharge and nursing facility admission on the same date but does not allow inpatient discharge and new inpatient admission on the same date.
Q When to use 99361
Can you explain the requirements for billing 99361, “Medical conference by a physician with interdisciplinary team of health professionals or representatives of community agencies to coordinate activities of patient care (patient not present)”?
A
This code is for case management services that require the physician to be responsible for direct care of the patient. It also requires that the physician coordinate or supervise other health care services needed by the patient. For example, some Medicaid carriers accept this code for face-to-face case conferences between a physician and health professionals or community agency representatives to coordinate care for children who have been sexually abused. Medicare and other payers that do not accept this code may accept care plan oversight codes for these types of services.
Initial assessment usually involves a lot of time determining the differential diagnosis, a diagnostic plan, and potential treatment options. Therefore, most pediatricians will report either an office or outpatient evaluation and management (E/M) code using time as the key factor or a consultation code for the initial assessment.
Physician Evaluation and Management Services
99201 Office or other outpatient visit, new patient; self limited or minor problem, 10 min.
99202 low to moderate severity problem, 20 min.
99203 moderate severity problem, 30 min.
99204 moderate to high severity problem, 45 min.
99205 high severity problem, 60 min.
99211 Office or other outpatient visit, established patient; minimal problem, 5 min.
99212 self limited or minor problem, 10 min.
99213 low to moderate severity problem, 15 min.
99214 moderate severity problem, 25 min.
99215 moderate to high severity problem, 40 min.
99241 Office or other outpatient consultation, new or established patient; self-limited or minor problem, 15 min.
99242 low severity problem, 30 min.
99243 moderate severity problem, 45 min.
99244 moderate to high severity problem, 60 min.
99245 moderate to high severity problem, 80 min.
Time may be used as the key or controlling factor when greater than 50% of the total physician face-to-face time is spent in counseling or coordination of care (Current Procedural Terminology 2010, American Medical Association, page 10).
NOTE: Use of these codes requires the following:
1) Written or verbal request for consultation is documented in the patient chart.
2) Consultant’s opinion as well as any services ordered or performed are documented in the patient chart.
3) Consultant’s opinion and any services that are performed are prepared in a written report, which is sent to the requesting physician or other appropriate source (Note: patients/parents may not initiate a consultation).
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A new patient is defined as one who has not received any face-to-face professional services from a physician, or another physician of the same specialty who belongs to the same group practice, within the past 3 years (Principles of CPT Coding [5th edition],
+99354 Prolonged physician services in office or other outpatient setting, with direct patient contact; first hour (use in conjunction with time-based codes 99201–99215, 99241–99245, 99301–99350)
+99355 each additional 30 min. (use in conjunction with 99354)
• Used when a physician provides prolonged services beyond the usual service (ie, beyond the typical time).
• Time spent does not have to be continuous.
• + Codes are add-on codes, meaning they are reported separately in addition to the appropriate code for the service provided (eg, office or other outpatient E/M codes, 99201–99215).
• Prolonged service of less than 15 minutes beyond the first hour or less then 15 minutes beyond the final 30 minutes is not reported separately.
Physician Non–Face-to-Face Services
99339 Care Plan Oversight—Individual physician supervision of a patient (patient not present) in home, domiciliary or rest home (e.g., assisted living facility) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (e.g., legal guardian)
and/or key caregiver(s) involved in patient’s care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes
99340 30 minutes or more
99358 Prolonged physician services without direct patient contact; first hour NOTE: This code is no longer an “add-on” service and can be reported alone.
+99359 each additional 30 min. (+ designated add-on code, use in conjunction with 99358)
99367 Medical team conference by physician with interdisciplinary team of healthcare professionals, patient and/or family not present, 30 minutes or more.
99441 Telephone evaluation and management to patient, parent or guardian not originating from a related E/M service within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
99442 11-20 minutes of medical discussion
99443 21-30 minutes of medical discussion
99444 Online evaluation and management service provided by a physician to an established patient, guardian or health care provider not originating from a related E/M service provided within the previous 7 days, using the internet or similar electronic communications network
Psychiatric Diagnostic or Evaluative Interview Procedures
90801 Psychiatric diagnostic interview examination
90802 Interactive psychiatric diagnostic interview examination using play equipment, physical devices, language interpretation, or other communication mechanisms Psychotherapy
90804 Individual psychotherapy, 20-30 min face-to-face with patient;
90805 with medical evaluation and management
90806 Individual psychotherapy, 45-50 min face-to-face with patient;
90807 with medical evaluation and management services
90808 Individual psychotherapy, 75-80 min face-to-face with patient;
90809 with medical evaluation and management services
90810 Individual psychotherapy, interactive, using play equipment, or other mechanisms, 20-30 min faceto-face with patient;
90811 with medical evaluation and management services
90812 Individual psychotherapy, interactive, 45-50 min face-to-face with patient;
90813 with medical evaluation and management services
90814 Individual psychotherapy, interactive, 75-80 min face-to-face with patient;
90815 with medical evaluation and management services
90846 Family psychotherapy (without patient present)
90847 Family psychotherapy (conjoint psychotherapy)(with patient present)
90849 Multiple-family group psychotherapy
90857 Interactive group psychotherapy
Other Psychiatric Services/Procedures
90862 Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy
90885 Psychiatric evaluation of hospital records, other psychiatric reports, and psychometric and/or projective tests, and other accumulated data for medical diagnostic purposes
90887 Interpretation or explanation of results of psychiatric, other medical exams, or other accumulated data to family or other responsible persons, or advising them how to assist patient
90889 Preparation of reports on patient’s psychiatric status, history, treatment, or progress (other than for legal or consultative purposes) for other physicians, agencies, or insurance carriers Psychological Testing
96101 Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI, Rorschach, WAIS), per hour of the psychologist’s or physician’s time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report
96102 Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI, Rorschach, WAIS), with qualified health care professional interpretation and report, administered
by technician, per hour of technician time, face-toface
96103 Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI, Rorschach, WAIS), administered by a computer, with qualified health care professional
interpretation and report
96105 Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, e.g., Boston Diagnostic Aphasia Examination) with
interpretation and report, per hour
96110 Developmental testing; limited (eg, Developmental Screening Test II, Early Language Milestone Screen), with interpretation and report
96111 Developmental testing; extended (includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized instruments) with interpretation and report
96116 Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), per hour of the psychologist’s or physician’s time, both face-to face time with the patient and time interpreting test results and preparing the report Nonphysician Provider (NPP) Services
99366 Medical team conference with interdisciplinary team of healthcare professionals, face-to-face with patient and/or family, 30 minutes or more, participation by a nonphysician qualified healthcare professional
99368 Medical team conference with interdisciplinary team of healthcare professionals, patient and/ or family not present, 30 minutes or more, participation by a nonphysician qualified healthcare professional
96150 Health and behavior assessment performed by nonphysician provider (health-focused clinical interviews, behavior observations) to identify psychological, behavioral, emotional, cognitive or social factors important to management of physical health problems, 15 min., initial assessment
96151 re-assessment
96152 Health and behavior intervention performed by nonphysician provider to improve patient’s health and well-being using cognitive, behavioral, social, and/or psychophysiological procedures designed to ameliorate specific disease-related problems,
individual, 15 min.
96153 group (2 or more patients)
96154 family (with the patient present)
96155 family (without the patient present)
Non–Face-to-Face Services: Telephone assessment and Management
98966 Telephone assessment and management service provided by a qualified nonphysician healthcare professional to an established patient, parent or guardian not originating from a related assessment and management service provided within the previous seven days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
98967 11-20 minutes of medical discussion
98968 21-30 minutes of medical discussion
98969 Online assessment and management service provided by a qualified nonphysician healthcare professional to an established patient, parent, guardian, or health care provider not originating from a related assessment and management service provided within the previous seven days nor using the internet or similar electronic communications network
Miscellaneous Services
99071 Educational supplies, such as books, tapes or pamphlets, provided by the physician for the patient’s education at cost to the physician