Code with confidence

Primary care physicians (PCPs) trying to boost their practice revenue usually consider a variety of options, from adding an ancillary service to moonlighting at the local emergency department. Sometimes, however, the easiest source of additional income is hiding in plain sight, in their own billing and coding procedures.

Whether due to fear of being audited, outdated practice workflows, or simple lack of knowledge, PCPs too often are billing and coding in a way that “leaves money on the table,” says Boyd R. Buser, D.O., FACOFP, vice president for health affairs and dean of the Kentucky College of Osteopathic Medicine, and a member of the Current Procedural Terminology (CPT) editorial panel.

The “money left on the table” challenge-and accompanying financial opportunity-will grow in 2015, when Medicare will begin paying for chronic care management (CCM) services. The relevant CPT code (99490) is for managing the care of patients with two or more chronic conditions (defined as conditions expected to last at least 12 months or until the patient’s death) outside of face-to-face visits.

The CCM code is time-based, and can be billed by the physician as well as other clinical staff members. The code can only be billed once per month per patient, so practices will need to track and aggregate all the time spent on relevant activities throughout the month. “It’s going to involve pulling some of the clinical staff into a process that’s not usually tracked well, because it’s not face-to-face care,” says Nancy Enos, FACMPE, CMPA, principal of Enos Medical Coding in Warwick, Rhode Island.

New opportunity to bill services separately

The opportunity the CCM code represents is the ability to bill separately for services that previously were bundled in other codes, and to bill for non face-to-face services. The Centers for Medicare and Medicaid Services has proposed a payment rate of $41.92 for the code that would be paid once per month per qualified patient. Eligibility to bill the code includes additional stipulations, including that patients have 24/7 access to care management services, and that the CCM services be delivered using an electronic health record.

When it comes to codes that Medicare is already paying for, those covering transitional care management (TCM)-the management of a patient’s transition from an inpatient to a community setting,-represent an untapped source of revenue for many PCPs. First proposed in 2012, Medicare began paying for TCM services at the start of 2013 under CPT codes 99495 and 99496.

Among their requirements is contact with the patient within either two or seven business days following discharge, and a face-to-face visit within either seven or 14 days of discharge, depending on the complexity of the medical decision-making involved in the patient’s care. In addition, the services covered under the codes can only be billed once per month per patient, and only on the 30th day following the patient’s discharge from the inpatient facility. 

Next: Why some providers don't bill for transitional care

Barriers to billing for transitional care

Because of the somewhat unusual requirements surrounding the codes, “a lot of providers aren’t taking the time to report them, because they think it’s too cumbersome to keep track of,” says Raemarie Jiminez, CPC, CBP, vice president for member and certification development at the American Academy of Professional Coders.

The interval between when the patient is seen and when the services can be billed has caused difficulty for some primary care practices, says Jeannine Z. Engel, MD, FACP, a frequent lecturer on coding issues for the American College of Physicians. “Generally when you see a patient and there’s some kind of note in your system, you drop a bill based on that note,” she says. “But you can’t drop a bill on the day you see the patient [under the TCM codes], and that’s challenging for practices.”

Consultants, and practices that have billed TCM codes say two steps are crucial to success. The first is knowing when a patient is discharged, since that triggers the timetable for the other required activities.

Provider, hospital coordination is key

“The key is coordination between the physician’s office and the hospital,” says David Ellington, MD, FAAFP, a family practitioner in Lexington, Virginia and a member of the CPT editorial panel. “As soon as the codes came out our practice called the administrator of our local hospital. Now we get a discharge summary by e-mail the day of the patient’s discharge, so we can start work on our end and contact the patient.”

Administrators at Via Christi Clinic in Newton, Kansas, began working on a system for tracking transition care management patients in 2013, says Terry L. Mills, MD, FAAFP, medical director of patient care systems for Via Christi Health, the clinic’s parent entity. The process, which is used at four of Via Christi’s 13 ambulatory locations, is overseen by patient care coordinators, who check area hospitals daily to ascertain which of their doctor’s patients have been discharged.

Next: The importance of a flow sheet

Via Christi developed a one-page flow sheet for tracking relevant dates and recording patient information such as required therapies and medication reconciliation. When a patient is discharged, Mills explains, the care coordinator begins a flow sheet and pulls the patient’s records. The coordinator tries to contact the patient within 48 hours of discharge, as required under the TCM codes, and documents the efforts on the flow sheet.

‘The flow sheet drives the whole process’

 “The flow sheet drives the whole process. When it is completed, everything Medicare requires to bill the code is performed, available, and served up to the physician,” he says.

Mills estimates that the TCM process prevents about 50 readmissions annually among the 10 PCPs at his clinic. “When you do the math, you realize the system cost savings are huge,” he says. 

Mills says that he uses the TCM codes four or five times per month in his own practice, with about two-thirds billed at the 99495 level and the remainder at the 99496. “The care is more organized, more understandable to the patient, and I’m rewarded as well. So that’s a win-win,” he says.

Via Christi’s results are not surprising, says Ellington. “The transition care codes are a perfect example of how good care comes out of good coding,” he says. “These codes have focused attention on the time when a patient goes home from the hospital, and the importance of coordinating care to cut down on readmissions. When that work is recognized and rewarded, it gets done and gets done well.”

Coding for end-of-life directives

Another non face-to-face service PCPs can consider in 2015 is time spent helping patients plan end-of-life care directives, using CPT codes 99497 and 99498. Code 99497 includes the first 30 minutes of explaining and discussing advance directives with the patient, a family member, or designated surrogate. Code 99498 covers each additional 30 minutes of counseling. As of mid-October, it was not known if Medicare would reimburse for the services.

Read: The physician's role in end-of-life decision-making

“Conversations like this go on every day around the country, and it’s been a problem for physicians to bill for them,” if it was the only reason for the patient’s visit, Ellington says. “In the past there was no evaluation and management code that accurately described that work. Now they’ll have it.”

Telehealth is another source of non face-to-face billing revenue. Since 2000, Medicare has paid for some telehealth services, such as office or outpatient visits, individual psychotherapy and pharmacologic management. Eligible beneficiaries are limited to those living in rural health shortage-designated areas or counties outside a Metropolitan Statistical Area. Providers submitting telehealth service claims should use the code for the service, along with the modifier “GT.”