2015 CPT Code Changes for E/M & Key Modifiers—Facts, Tidbits & Highlights

Written by Brooke Haycraft, CEMC, CFPC, CPC-H, CPC

Current Procedural Terminology’s (CPT) new codes for 2015 have been released and are patiently waiting to be utilized. Being able to understand the new CPT codes and modifiers pertinent to your practice will help providers obtain the proper payment for services performed. Focusing on Evaluation and Management, below are highlights of code changes, new codes, and key modifiers that are available for use in 2015.

Modifiers

Modifier 59 is appended to signify a distinct procedural service from other procedures or services performed within the same provider visit that would normally be considered bundled services. This modifier is utilized to identify a variety of coding situations, including different encounters and anatomic sites to distinct services. Because this modifier is appended in a variety of circumstances, it is often subject to incorrect usage; modifier 59 is often used as a primary way to bypass Medicare National Correct Coding Initiative (CCI) edits. CMS has also noted that the modifier -59 often overrides the CCI bundling edit in the same circumstance for which the modifier was originally created.

In an effort to reduce billing errors and improper use of modifier 59, CMS has introduced four subset modifiers (collectively referred to as –X {EPSU} modifiers);

• XE Separate encounter—Service that is distinct because it occurs during a separate encounter.
• XS Separate structure—Service that is distinct because it is performed on a separate organ/structure.
• XP Separate practitioner—A service that is distinct because it is performed by a different practitioner.
• XU Unusual non-overlapping service—the use of a service that is distinct because it does not overlap usual components of the main service.

CMS will continue to recognize the -59 modifier in 2015 but notes that CPT instructions state that the -59 modifier should not be used when a more descriptive modifier is available.

Evaluation and Management

A.    99481 (Total body systemic hypothermia in a critically ill neonate per day) and 99482 (Selective head hypothermia in a critically ill neonate per day) have been DELETED and replaced with a NEW combination code, 99184.

·       99184 is defined as, “Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling.”

o   CPT states that 99184 may not be reported more than ONCE per hospital stay.

o   If 99184 is discontinued and reinitiated at a later time and/or date, this code would again be allowed for reimbursement.

o   Because there is no E/M service in CPT code 99184, this hypothermia service is now located in the Medicine section of the 2015 CPT book.

o   99184 is considered a separately reportable and reimbursable service from E/M codes utilized on the same date of service.

B.     99490, Chronic Care Management

·       NEW code that is defined by CPT “as chronic care management services, 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: multiple (two or more) chronic conditions expected to last at least 12 months, or at least until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored.”

o   Required Elements to bill for 99490—

o   Management of two or more chronic conditions expected to last at least 12 months or until the death of the patient.

o   Chronic conditions (i.e., life threatening conditions, this code is not intended for management of osteoarthritis) place patient at high risk of death, acute exacerbation or decline.

o   Comprehensive care plan established, implemented, revised, or monitored.

·       CMS will adopt CPT code 99490 instead of the initially proposed, ‘G’ code.

·       Approximate reimbursement by Medicare is $40.

·       Providers should check with commercial payors regarding payment—not all commercial insurers reimburse for ‘non-face-to-face’ codes.

           

C.    99487, Complex Chronic Care Management Services.

·       99487 has been REVISED to include criteria required for chronic care management services.

·       99487 is defined as complex chronic care management services, with the following required elements:

o   .Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the death of the patient.

o   Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.

o   Establishment or substantial revision of a comprehensive care plan.

o   Moderate or high complexity medical decision making.

o   60 minutes of clinical staff time directed by a physician of other qualified health care professional, per calendar month.

·       Classic patients for complex chronic care management services usually exhibit one or more of the following:

o   Need for coordination of multiple specialties and services.

o   Inability to perform activities of daily living without assistance of caregiver.

o   Psychiatric or other medical complexities that complicate patient care.

o   Difficulty in obtaining access to care.

D.    99497 & 99498, Advanced Care Planning

·       NEW codes. 99497 is defined as, “Advanced care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.  99498 represents, ‘Advanced care planning, each additional 30 minutes.”

o   No active management of medical problems is performed during this time period.

·       An E/M service may be reported separately on the same date except for critical care, inpatient neonatal and pediatric critical care, and initial and continuing

o   intensive care services.

o   Medicare will not reimburse for these services in 2015 and has assigned these services as a status indicator of ‘I’, which means not valid for Medicare purposes.