Overlooked codes physicians should consider

It’s a common complaint heard among primary care physicians: Evaluation and management (E/M) codes don’t adequately capture the time, skill, and resources necessary to plan and coordinate care for patients with complex medical needs. Although new, streamlined E/M guidelines for 2021 may help, several existing remedies can enable physicians to capture additional revenue for the services they provide.

More specifically, the U.S. Government Accountability Office (GAO) recently published a list of 58 CPT codes that fall under the category of “longitudinal comprehensive care planning” (LCCP) for Medicare beneficiaries diagnosed with a serious or life-threatening illness. These codes include elements of shared decision-making through interdisciplinary care as well as development of a care plan to address the following:

• Progression of the disease and treatment options

• Beneficiary’s goals, values, and preferences

• Resources and social supports that can mitigate the beneficiary’s health risks

Revenue from these LCCP codes can help physicians implement workflows and hire additional staff to support value-based care, says Abigail Burns, senior analyst at Advisory Board, a healthcare consulting company in Washington, D.C. “These codes are CMS’s way of providing a fee-for-service revenue source to enable providers to invest in the resources they need to help them succeed under value,” she says.

LCCP codes are becoming more common because commercial payers are increasingly paying for them, says Toni Elhoms, CCS, CPC, CEO of Alpha Coding Experts LLC, a coding consulting company in Orlando, Fla. Another reason is the trend toward capitated contracts under which physicians receive per-member per-month payments.

“It’s a lot more cost effective to be proactive rather than reactive,” she says, adding that many LCCP services focus on disease management and prevention as well as care coordination with the goal of keeping people healthy. “If you’re reactive-and the patient requires more intensive services during a particular month-you’re on the hook and don’t receive additional compensation.”

Here are the most significant revenue opportunities for primary care and tips for how physicians can overcome the barriers that may prevent them from performing (and correctly billing) these LCCP services.

1 Chronic care management (CCM)
CPT codes: 99490 ($42.17), 99491 ($83.97), 99487 ($92.98), 99489 ($46.49)
Type of patient: Patients with two or more chronic conditions expected to last at least 12 months or until the patient’s death
Billing frequency: Per month
Who can provide/bill: Any
physician or other qualified healthcare provider

2 Transitional care management (TCM)
CPT codes: 99495 ($166.50) and 99496 ($234.97)
Type of patient: Patients with medical and/or psychosocial problems that require moderate or high complexity medical decision-making during the transition to a community setting following discharge from certain inpatient hospital settings
Billing frequency: 30-day period beginning on the date of discharge from an inpatient setting
Who can provide/bill: Any physician or other qualified healthcare provider

Barrier: Need to rethink staff responsibilities. Although some practices may need to hire an additional staff member or work with a third-party vendor, leveraging the existing care team is ideal, says Burns. For example, an RN can provide these services for complex patients while an LPN can provide them for less complex patients, though the physician still needs to be involved in developing the care plan. Using a medical assistant to perform some of the administrative tasks associated with TCM and CCM is also helpful, she adds. For example, they can obtain discharge information, provide patient education, or connect patients with community resources.<

Barrier: Perceived lack of return on investment for CCM. Although CCM itself doesn’t pay a large sum, the financial gains occur as practices identify, perform, and bill other necessary services (e.g., wellness visits, vaccines, and office visits), says Vanessa Bisceglie, MBA, BS, OHCC, PMP, NCP, CEO of Care Vitality in Skokie, Illinois, a third-party care management vendor that provides CCM, TCM and BHI services as an extension to a provider’s practice. CCM also helps physicians boost their MIPS scores and achieve bonuses if they’re part of an Accountable Care Organization. “They need to look at the big picture,” she says. “It’s about catching things earlier and keeping patients out of the hospital. By doing that, revenue comes back to the office instead of going to the ER and the hospital.”

In addition, HCPCS code G0506 (comprehensive assessment and care planning) is a one-time Medicare-specific CCM code that many providers overlook, says Elhoms. This code, which pays $63.43, is for the initiation of CCM for new patients or patients not seen within one year prior to the commencement of CCM. When the provider who gains consent and initiates the comprehensive care plan as part of the office visit personally performs the extensive assessment and care plan beyond the usual effort associated with the E/M service, annual wellness visit, initial preventive physical exam, that same provider can also bill G0506, she adds.

Barrier: Tracking time for CCM. CCM is only billable once per month, and each code has associated time requirements. If the EHR doesn’t automatically track time spent, then practices need to create their own solutions, says Kathy Pride, RHIT, CPC, CCS-P, CPMA, senior vice president of coding and documentation services at Panacea Healthcare Solutions Inc., a healthcare IT consulting company in St. Paul, Minn. Even something as simple as an encrypted Excel spreadsheet with a tab for each month and columns for each patient’s name, date, and time the provider spent rendering CCM can be helpful, she adds. Providers can insert a formula into the spreadsheet that automatically calculates the total number of minutes for each patient and refer to this spreadsheet to easily glean the total time spent.

Barrier: Too many documentation requirements for CCM and TCM. The good news is that EHR vendors are increasingly building templates to help physicians satisfy all documentation requirements for CCM and TCM, says Bisceglie. Physicians can also work with third-party vendors to develop these templates. However, CCM and TCM are about more than simply checking off a box in a template. These services require providers to find and address all of a patient’s care gaps, which is why it’s important to learn the components of each code and doing what’s best for each patient.
“Providers need to make sure they’re providing the full scope of the service that’s required to bill for the code and providing value to the patient,” says Bisceglie. This means tackling everything from coordinating care with specialists, helping patients take their medications correctly, identifying and reconciling duplicate prescriptions, and addressing social determinants of health, she adds.

Barrier: Obtaining patient consent for CCM. Obtaining consent (and thus getting patients to agree to a coinsurance or deductible) is a relatively easy process if physicians focus on providing value to the patient, says Bisceglie. She suggests using the following language: “This is a service you’re not receiving but something that Medicare covers to help us coordinate your care. I think you can benefit from this service, and it can help us make sure we provide you with the best possible care.”

3 Advance care planning (ACP)
CPT codes: 99497 ($86.49) and 99498 ($76.04)
Type of patient: No restrictions
Billing frequency: No limits
Who can provide/bill: Any physician or other qualified healthcare provider

Barrier: Physicians don’t know these codes exist. Medicare pays for ACP when physicians perform it as part of the AWV or as a separate Medicare Part B medically necessary service, says Elhoms. The only difference is whether the patient’s deductible and coinsurance apply. When the same provider performs the AWV and ACP on the same day-and bills it with modifier -33 for preventive service-Medicare waives the deductible and Part B coinsurance. To avoid denials, physicians must document the total time spent discussing ACP, what the discussion entailed, and the outcome (i.e. whether the patient signed any documents).

4 Behavioral health integration (BHI)
CPT code: 99484 ($48.65)
Type of patient: Patients with any mental, behavioral health, or psychiatric condition who may warrant this service
Billing frequency: Per month
Who can provide/bill: Any physician or other qualified healthcare provider

Barrier: No return on investment. One potential reason for this is physicians not billing BHI when they perform CCM. Although BHI may not apply in some cases, these two services tend to go hand-in-hand because mental health conditions sometimes drive exacerbation of chronic conditions (e.g., depression that causes worsening diabetes). Often physicians only bill for CCM even though they spend time assessing the patient’s behavioral health condition and coordinating care with a specialist, says Bisceglie. The only caveat is that services they perform to meet criteria for BHI cannot count toward meeting the criteria for CCM, she adds.

Consultants can help physicians identify the personnel necessary to provide BHI (and what licenses and other qualifications may be necessary depending on state requirements), create a payer matrix to determine coverage for the service, and even examine the physical office space to determine whether additional offices are needed or whether the practice needs to shift walls, add doors, etc. to promote efficient workflows, says Sonal Patel CPMA, CPC, CMC, a healthcare coder and compliance consultant with Nexsen Pruet LLC, a business law firm in Charleston, SC.

“Physicians will definitely see a return on investment if everything is done compliantly the first time,” she adds.

5 Cognitive impairment
assessment
CPT code: 99483 ($263.81)
Type of patient: Patients with cognitive impairment
Billing frequency: Once every 180 days
Who can provide/bill: Any physician or other qualified healthcare provider

Barrier: Physicians don’t know this code exists. Physicians may be performing elements of this code during an AWV or IPPE without realizing they can perform a more in-depth assessment using standardized instruments and then bill CPT code 99483, says Elhoms. From a workflow standpoint, physicians typically see signs of impairment (e.g., poor historian, confusion, or forgetfulness) during the AWV or IPPE and tell the patient they must come back for an assessment. Although physicians can technically report the AWV or IPPE with CPT code 99483, it makes more sense to schedule a separate visit so the physician can block off more time (usually an hour) to perform all of the components of the code, she adds.