EM Code Changes in CPT 2018

by  Amy C. Pritchett, BSHA, CCS, CPC, CPMA, CPC-I, CEDO, CANPC, CASCC, CEDC, CRC, ICDCT-CM/PCS
May 30th, 2018

It is that time of year again! The time to throw out the old and bring in the new. With the release of the CPT 2018 updates, we will see major changes in coding throughout the E/M section. During the update, many new codes and chapters were added to allow for Collaborative Care Management and new Behavioral Health Management codes.

This article will guide you through the complex changes that will occur January 1, 2018.

Cognitive Assessment and Care Plan Services Added

99483 Assessment of and care planning for a patient with cognitive impairment, requiring an independent historian, in the office or other outpatient, home or domiciliary or rest home, with all of the following required elements.... Typically 50 minutes are spent face-to-face with the patient and/or family or caregiver.

Guideline: Cognitive assessment and care plan services are provided when a comprehensive evaluation of a new or existing patient, who exhibits signs and/or symptoms of cognitive impairment, is required to establish or confirm a diagnosis, etiology, and severity for the condition. This service includes a thorough evaluation of medical and psychosocial factors, potentially contributing to increased morbidity. Do not report cognitive assessment and care plan services if any of the required elements are not performed or are deemed unnecessary for the patient's condition. For these services, see the appropriate evaluation and management code. A single physician or other qualified health care professional should not report 99483 more than once every 180 days.

New code 99483 Assessment of and care planning for a patient with cognitive impairment, requiring an independent historian, in the office or other outpatient, home or domiciliary or rest home, with all of the following required elements.... Typically 50 minutes are spent face-to-face with the patient and/or family or caregiver replaces HCPCS G0505. Cognitive assessment and care plan services are provided when a comprehensive evaluation of a new or existing patient, who exhibits signs and/or symptoms of cognitive impairment, is required to establish or confirm a diagnosis, etiology, and severity for the condition. This service includes a thorough evaluation of medical and psychosocial factors, potentially contributing to increased morbidity. Do not report cognitive assessment and care plan services if any of the required elements are not performed or are deemed unnecessary for the patient's condition. For these services, see the appropriate evaluation and management code. Cognitive assessment and care planning may be reported every 180 days. Do not report with other E/M services.

Psychiatric Collaborative Care Management Services Added

Three new codes (99492-99494) report initial and subsequent psychiatric collaborative care management (CoCM). Per the American Psychiatric Association, CoCM services:

...typically [are] provided by a primary care team consisting of a primary care physician and a care manager who work in collaboration with a psychiatric consultant, such as a psychiatrist. Care is directed by the primary care team and includes structured care management with regular assessments of clinical status using validated tools and modification of treatment as appropriate. The psychiatric consultant provides regular consultations to the primary care team to review the clinical status and care of patients and to make recommendations.

To report CoCM, all of the bulleted items must be performed and documented, and the time threshold must be met, as demonstrated in the chart, below. Do not report 99492 and 99493 within the same calendar month

See table on page 12

New Codes for General Behavioral Health Integration Care Management

New code 99484 Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional, per calendar month, with the following required elements... replaces HCPCS code G0507 to report general behavioral health integration (BHI) services, which incorporate principles associated with collaborative care. To report these services, all bulleted items listed in the code descriptor must be performed and documented, and the time threshold (in this case, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional, per calendar month) must be met. Do not report 99484 with 99492, 99493, 99494 (see above) in the same calendar month

Anticoagulation Management Gets an Overhaul

Codes 99363 and 99364 for anticoagulation management are deleted and replaced by new (medicine section ) codes 93792 Patient/caregiver training for initiation of home international normalized ratio (INR) monitoring under the direction of a physician or other qualified health care professional, face-to-face, including use and care of the INR monitor, obtaining blood sample, instructions for reporting home INR test results, and documentation of patient's/caregiver's ability to perform testing and report results and 93793 Anticoagulant management for a patient taking warfarin, must include review and interpretation of a new home, office, or lab international normalized ratio (INR) test result, patient instructions, dosage adjustment (as needed), and scheduling of additional test(s), when performed.

Due to the critical nature of thinning blood or reducing its clotting factor, patients on warfarin require constant oversight, along with International Normalized Ration (INR) testing. The medication is adjusted, as needed, to provide the best level of anticoagulation in the blood. The patient is reminded of the specific dietary needs, and observed for possible bruising. Anticoagulation management codes are used to report this oversight, which includes ordering, review, and interpretation of the INR testing, communication with the patient, and dosage adjustments, as necessary. Code 93792 reports the education for the patient or caregiver for home INR monitoring, while 93793 reports the provider's management and oversight.

Revised Guidelines for Initial Observation Care and More

New text clarifies that initial observation codes 99218-99220:

... report the encounter(s) by the supervising physician or other qualified healthcare professional with the patient when designated as a hospital "observation status." This refers to the initiation of observation status, supervision of the care plan for the observation, and performance of periodic reassessments. For observation encounters by other physicians, see office or other outpatient consultation codes (99241-99245) or subsequent observation care (99224-99226) as appropriate.

The term "outpatient hospital" is added to code descriptors to clarify that observation services (including observation care discharge, 99217) are specific to outpatient status (POS 22). Do not report observation for patients admitted to the hospital.

There are several important changes to E/M section guidelines and parenthetical instructions.

New guidelines clarify that prolonged service codes 99354-99357 involve direct patient contact, beyond the usual service, in either the inpatient or outpatient setting. The guidelines define direct patient contact as "face-to-face," but further including "additional non-face-to-face services on the patient's floor or unit in the hospital or nursing facility during the same session."

New guidelines state that telephone services code 99441-99443 are not reported with 93792, 93793 for home and outpatient INR monitoring.

Revised guidelines clarify that time-based critical care services (99291, 99292) may not be reported by the same individual (or a different individual of the same specialty or group) when reporting neonatal or pediatric critical care services (99468-99476) for the same patient on the same day. But, 99291 and 99292 may be reported by an individual of a different specialty (from either the same or different group) on the same day as neonatal or pediatric critical care services. Further, per CPT®, "Critical care interfacility transport face-to-face (99466, 99467) or supervisory (99485, 99486) services may be reported by the same or different individual of the same specialty and same group, when neonatal or pediatric critical care services (99468-99476) are reported for the same patient on the same day."


Amy C. Pritchett, BSHA, CCS, CPC, CPMA, CPC-I, CEDO, CANPC, CASCC, CEDC, CRC, ICDCT-CM/PCS, has been a coder for over 25 years with her most recent position being held at Change Healthcare the Facility Coding Services Line Manager. She has many years of experience in several different areas of coding and serves as an interim instructor in her hometown of Mobile, AL. Pritchett has owned and operated her own medical billing and coding company, Gulf Coast HIM Solutions located in Mobile, AL. She shares her expertise in publications and as a lecturer at conferences such as HealthCon, and, Coding-Con for The Coding Institute. She has served as the president, vice president, Member Development and Education officers of the Mobile, AL local chapter.

References:

EM Code Changes in CPT 2018. (2018, May 30). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/em-code-changes-in-cpt-2018-33995.html

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