Tennessee Chapter of the American Academy of Pediatrics 1 Coding to Support Medical Home Presented by Janet Smith, RHIT, CPC AHIMA Approved ICD-10 Trainer Coding Educator

The Tennessee Chapter of the American Academy of Pediatrics (TNAAP) is an independent organization. The information contained herein is intended for reference purposes only, and any other use (including, without limitation, copying, transmission or dissemination) is strictly prohibited. TNAAP attempts to provide accurate information; however, neither the publisher, editors, board members, contributors nor consultants warrant, guarantee or will be responsible for the accuracy, completeness, appropriateness or acceptability of any information contained herein. The materials and information provided by TNAAP do not substitute for the professional judgment of a medical practitioner or provider. The American Medical Association (AMA) claims copyright (2013) in the CPT codes, nomenclature and other data. All use of the AMA’s information shall be in accordance with the rights granted, if any, directly to a medical practitioner or provider by the AMA. Tennessee Chapter of the American Academy of Pediatrics 2.

TOPICS: Evaluation and Management Prolonged Services After-hours Codes Care Plan Oversight Complex Chronic Care Coordination Transitional Care Management Developmental/Behavioral Screening Tennessee Chapter of the American Academy of Pediatrics 3

New Patient E/M of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient Age < 1 year Ages 1 – 4 years Ages 5 – 11 years Ages 12 – 17 years Ages 18 – 39 years Tennessee Chapter of the American Academy of Pediatrics 4

Established Patient Reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient Age < 1 year Ages 1 – 4 years Ages 5 – 11 years Ages 12 – 17 years Ages 18 – 39 years Tennessee Chapter of the American Academy of Pediatrics 5

Separately Reportable Services with EPSDT/Preventive: Evaluation and Management (preventive) Hearing/Vision Screens Vaccine Administration Lab procedures such as Hemoglobin and Lead Use of Developmental/Behavioral Screening Tools Health Risk Assessments Significant and Separately Identifiable E/M services (eg, sick) Unrelated Procedures (eg, wart removal) Tennessee Chapter of the American Academy of Pediatrics 6

New Patients – Straightforward, 10 minutes – Straightforward, 20 minutes Low, 30 minutes Moderate, 45 minutes High, 60 minutes Tennessee Chapter of the American Academy of Pediatrics 7

Established Patients – Nurse visit, 5 minutes Straightforward, 10 minutes – Low, 15 minutes – Moderate, 25 minutes – High, 40 minutes Tennessee Chapter of the American Academy of Pediatrics 8

If the provider is spending at least 25 minutes with the patient and over 50% of that time is counseling and coordinating care, can be reported. Provider must document time and describe the counseling/care coordination provided Tennessee Chapter of the American Academy of Pediatrics 9

Time is face-to-face time with the patient for office and other outpatient visits and as unit/floor time for hospital and other inpatient visits A unit of time is attained when the mid-point is passed ◦ For example, an hour is attained when 31 minutes have elapsed (more than midway between 0 and 60 minutes). A second hour is attained when a total of 91 minutes have elapsed. When codes are ranked by typical times and the actual time is between two typical times, the code with the time closest to the actual time is used. Tennessee Chapter of the American Academy of Pediatrics 10

99214 = 25 minutes = 40 minutes If the provider spends 35 minutes with the patient and over 50% of the time is spent in counseling/coordination of care, the provider can report because the time falls closer to 40 minutes than 25 minutes. Tennessee Chapter of the American Academy of Pediatrics 11

CodeTypical TimeMinimum Time minN/A min16 min min26 min min38 min min53 min minN/A min8 min min13 min min21 min min33 min Tennessee Chapter of the American Academy of Pediatrics 12

CodeMC 2013 FeeDifference (from previous level) 99212$ $70.63$ $104.02$ $139.77$35.75 Tennessee Chapter of the American Academy of Pediatrics 13

99354 and Prolonged Services With Direct Face-to-Face Contact  Time spent must be face-to-face with the patient/family  Reported with any level E/M service when the primary E/M code has an assigned time  Time does not have to be continuous but is reported for services provided on the same calendar day Tennessee Chapter of the American Academy of Pediatrics 14

reported for prolonged service of 30 to 74 minutes – reported for each additional 30 minutes beyond the first hour Tennessee Chapter of the American Academy of Pediatrics 15

A 9-month-old previously healthy child is seen in follow-up for failure to gain weight and increasing irritability with recurrent bouts of constipation. Because of a family history of gluten intolerance, the physician wants to refer the child to a pediatric gastroenterologist. The parents are resistant to the referral. A total of 40 minutes was spent in providing the face-to-face E/M service and 30 minutes was spent in counseling the parents. Office visit – (40 minutes average time) Prolonged service 30 minutes Tennessee Chapter of the American Academy of Pediatrics 16

CodeFee 99215$ $95.87 Total = $ For each additional 30 minutes: CodeFee 99355$93.60 Tennessee Chapter of the American Academy of Pediatrics 17

99358 and are used when a physician provides prolonged service not involving direct (face-to-face) care that is beyond the usual non-face-to-face component of physician service time Tennessee Chapter of the American Academy of Pediatrics 18

● Reported with another physician service, including E/M service at any level ● May be reported on a different date than the primary service to which it is related ● Must relate to a service or patient where direct (face-to-face) patient care has occurred or will occur and relate to ongoing patient management ● A typical time for the primary service need not be established Tennessee Chapter of the American Academy of Pediatrics 19

● and are used to report the total duration of non face-to-face time providing prolonged service, even if the time is not continuous ● should only be used once per date for the first hour of prolonged service ● is used to report each additional 30 minutes beyond the first hour regardless of the place of service Tennessee Chapter of the American Academy of Pediatrics 20

● Do not report and for time spent in: Medical team conference Care plan oversight services Or other non-face-to-face codes that have more specific codes and no upper time limit Tennessee Chapter of the American Academy of Pediatrics 21

The provider spends 40 minutes in his office reviewing extensive medical records that are received the day after a patient is admitted to the hospital. Report Tennessee Chapter of the American Academy of Pediatrics 22

CodeFee $ For each additional 30 minutes: CodeFee $50.95 Tennessee Chapter of the American Academy of Pediatrics 23

Total Duration of Prolonged Services Code(s) less than 30 minutesNot reported separately minutes (1/2 hr. - 1 hr. 14 min.) X 1 or X (1 hr. 15 min. - 1 hr. 44 min.) X 1 and X 1 or X 1 and X1 105 or more (1 hr. 45 min. or more) X 1 and X 2 or X 1 and X 2 or more for each additional 30 minutes Tennessee Chapter of the American Academy of Pediatrics 24

99050 – Provided in office at times other than regularly scheduled office hours, or days when office is normally closed (eg, holidays, Saturday, or Sunday) in addition to basic service Tennessee Chapter of the American Academy of Pediatrics 25

Regular office hours are M-F 8:00 am - 5:00 pm Patient is seen at 6:00 pm Report E/M and 99050:   Tennessee Chapter of the American Academy of Pediatrics 26

Services provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service Tennessee Chapter of the American Academy of Pediatrics 27

Regular office hours are 8:00 to 12:00 on Saturday Patient is seen at 9:00 on Saturday Report E/M service and ie:   Tennessee Chapter of the American Academy of Pediatrics 28

99050 and do not have established RVUs Typical Reimbursement range for 99050: $ $30.00 Most payers do not reimburse for (**You may be able to negotiate with payers to use for “posted after-hours care”) Tennessee Chapter of the American Academy of Pediatrics 29

Recurrent physician supervision of a complex patient who requires multidisciplinary care and ongoing physician involvement. These services are not face to face and reflect the complexity of time required to supervise the care of the patient. Tennessee Chapter of the American Academy of Pediatrics 30

Regular physician development and/or revision of care plans Review of subsequent reports of the patient’s status Review of related laboratory or other diagnostic studies Communication (including telephone calls) for purposes of assessment or care decisions with health care professionals, family members…involved in the patient’s care Team conferences Tennessee Chapter of the American Academy of Pediatrics 31

Reported based on the amount of time spent by the physician within a calendar month beginning with the first day of the month and ending with the last day of the month Reported based on the patient’s location (eg, home, hospice) and the total time spent by the physician with in the calendar month. Less than 15 minutes cumulative time within a calendar month cannot be reported Reported separately from other E/M services Tennessee Chapter of the American Academy of Pediatrics 32

99339 – Individual physician supervision of a patient (patient not present) in home … minutes >30 minutes Tennessee Chapter of the American Academy of Pediatrics 33

4-year old child with cerebral palsy at home. Provider documents time spent on telephone calls with mother regarding team conference, makes revisions to plan of care, refers the child to speech therapy, and discusses with her the assessment and plan. A total of 43 minutes was spent in the provision of care plan oversight. Report Tennessee Chapter of the American Academy of Pediatrics 34

CodeFee 99340$ Care plan oversight billed for 12 months = $1, per patient! Tennessee Chapter of the American Academy of Pediatrics 35

99374 – Physician supervision of a patient under care of a home health agency (patient not present) in home, domiciliary, or equivalent environment… minutes >30 minutes Tennessee Chapter of the American Academy of Pediatrics 36

4-year old child with cerebral palsy under care of home health agency. Provider documents time spent on telephone calls with mother regarding team conference, makes revisions to plan of care, refers the child to speech therapy, and discusses with her the assessment and plan. A total of 43 minutes was spent in the provision of care plan oversight. Report Tennessee Chapter of the American Academy of Pediatrics 37

CodeFee 99375$ Care plan oversight billed for 12 months = $1, per patient! Tennessee Chapter of the American Academy of Pediatrics 38

Complex Chronic Care Coordination and Transitional Care Management Codes for Providers AND Clinical Staff Time Tennessee Chapter of the American Academy of Pediatrics

Patient-centered management and support services provided by physicians, other qualified health care professionals, and clinical staff Tennessee Chapter of the American Academy of Pediatrics 40

● Patients in home or in rest home, or assisted living facility ● Clinical staff implementing a care plan directed by the physician ● Address the coordination of care by multiple disciplines and community service agencies ● The reporting individual provides or oversees the management and/or coordination or services, as needed for all medical conditions, psychosocial needs, and activities of daily living Tennessee Chapter of the American Academy of Pediatrics

● These services include moderate- or high-complexity medical decision-making within a calendar month ● A plan of care should be documented and shared with the patient and/or caregiver ● The face-to-face and non-face-to-face time spent by the clinical staff in communicating with the patient and/or family, caregivers, other professionals and agencies; revising, documenting and implementing the care plan; or teaching self management is used in determining the clinical staff time for the month Tennessee Chapter of the American Academy of Pediatrics 42

99487 – First hour of clinical staff time directed by a physician or other qualified health care professional with no face-to-face visit, per calendar month – First hour of clinical staff time directed by a physician or other qualified health care professional with one face-to-face visit, per calendar month – each additional 30 minutes (list separately in addition to the code for primary procedure) Additional E/M services beyond the 1 st visit may be reported separately Tennessee Chapter of the American Academy of Pediatrics 43

● communication (with patient, family members, guardian or caretaker, surrogate decision makers, and/or other professional) regarding aspects of care ● communication with home health agencies and other community services collection of health outcomes data and registry documentation ● patient and/or family/caretaker education to support self- management, independent living, and activities of daily living ● assessment and support for treatment regimen adherence and medication management ● identification of available community and health resources; ● facilitating access to care and services needed by the patient and/or family ● development and maintenance of a comprehensive care plan Tennessee Chapter of the American Academy of Pediatrics 44

A 6-year old has spastic quadriplegia, gastrostomy, gastroesophageal reflux with recurrent bouts of aspiration pneumonia and reactive airway disease, chronic seizure disorder, failure to thrive and severe neurodevelopmental delay. He receives home occupational, physical, and speech therapy services A total of 40 minutes was spent care coordination for the month Code Tennessee Chapter of the American Academy of Pediatrics

A 12-year old has severe atopic disease and recurrent asthma, which has led to multiple ED visits, hospital admissions, lost school days, and behavioral adjustment reactions. The child has one office visit and 40 minutes was spent in care coordination during the calendar month Code Tennessee Chapter of the American Academy of Pediatrics

Complex Care Coordination = $ = $ (with face-to-face visit) = $40.12 Tennessee Chapter of the American Academy of Pediatrics

● For new or established patients whose medical and/or psychological problems require moderate or high complexity medical decision-making ● During transitions in care from an inpatient hospital setting (including observation status in a hospital, or skilled nursing facility/nursing facility) ● To the patient’s community setting (home, domiciliary, rest home, or assisted living) Tennessee Chapter of the American Academy of Pediatrics 48

● TCM is comprised of one face-to-face visit within the specified time frames, in combination with non-face-to-face time that may be performed by the physician or other qualified health care professional and/or licensed clinical staff under his or her direction ● Additional E/M services beyond the 1 st visit may be reported separately Tennessee Chapter of the American Academy of Pediatrics 49

Requirements: Within 2 business days of discharge, an interactive contact with the patient or caregiver must take place. This contact can be face-to-face or by telephone or electronic means A face-to-face visit must take place within 7-14 calendar days following discharge depending on the complexity of the patient and code reported. Medication reconciliation and management must take place no later than the date of the first face-to-face visit following discharge Tennessee Chapter of the American Academy of Pediatrics 50

99495 Communication with the patient and/or caregiver within 2 business days of discharge Medical decision making of at least moderate complexity Face-to-face visit, with 14 calendar days of discharge Communication with the patient and/or caregiver within 2 business days Medical decision making of high complexity Face-to-face visit, within 7 calendar days of discharge Tennessee Chapter of the American Academy of Pediatrics 51

● communication (with patient, family members, guardian or caretaker, surrogate decision makers, and/or other professionals) regarding aspects of care ● communication with home health agencies and other community services utilized by the patient ● patient and/or family/caretaker education to support self- management, independent living, and activities of daily living ● assessment and support for treatment regimen adherence and medication management ● identification of available community and health resources ● facilitating access to care and services needed by the patient and/or family Tennessee Chapter of the American Academy of Pediatrics 52

Non-face-to-face services provided by the physician or other qualified health care professional may include: ● obtaining and reviewing the discharge information; ● reviewing diagnostic tests and treatments; ● interaction with other qualified health care professionals who will assume or reassume care of the patient…; ● education of patient, family, guardian, and/or caregiver; ● establishment or reestablishment of referrals and arranging for needed community services ● assistance in scheduling follow-up with community providers and services. Tennessee Chapter of the American Academy of Pediatrics 53

A 6-year old who is neurologically impaired and developmentally delayed and has chronic seizure disorder is discharged from the hospital after an admission for breakthrough seizures. Two days after discharge the physician speaks with the mother. The clinical staff assesses adherence with treatment plan and educates the parents on management of the child. The child is seen for an office visit 10 days after discharge. Medical decision making is moderate Code Tennessee Chapter of the American Academy of Pediatrics

A 6-month old born at 25 weeks’ gestation with a chronic lung disease on home oxygen, diuretics, bronchodilators, and high-caloric formula is discharged from the hospital after admission for respiratory failure. The physician speaks with the mother the day after discharge. Clinical staff assesses adherence to the treatment plan and educates parents on management of the child. The child is seen in follow up in 5 days. Medical decision making is high Code Tennessee Chapter of the American Academy of Pediatrics

Transitional Care Management (TCM) = $ = $ Tennessee Chapter of the American Academy of Pediatrics 56

Tennessee Chapter of the American Academy of Pediatrics

Specific Age Recommendations from the AAP to allow for: Earlier detection Earlier treatment Better outcomes for children with developmental delays Most payers recognize the value and will reimburse for this service Tennessee Chapter of the American Academy of Pediatrics 58

Developmental Surveillance is recommended at ALL ages as part of the history Psychosocial/Behavioral Assessment is recommended at ALL ages Tennessee Chapter of the American Academy of Pediatrics 59

Recommended Screenings: Developmental Screening 9, 18 and 30 months Autism Screening 18 and 24 months Depression Screening (*New) years Alcohol and Drug use Assessment years Tennessee Chapter of the American Academy of Pediatrics 60

96110 – Developmental screening, with interpretation and report, per standardized instrument form Examples of validated screening tools include but are not limited to:  M-CHAT  PEDS  Ages and Stages  Pediatric Symptom Checklist  Vanderbilt Scale for ADHD  PHQ-2 Tennessee Chapter of the American Academy of Pediatrics 61

96110 is normally utilized in conjunction with an EPSDT visit If this screening is done in conjunction with preventive service, report modifier -25 with the preventive service code Tennessee Chapter of the American Academy of Pediatrics 62

If more than one screening tool is used, i.e., PEDS and MCHAT: Use modifier -59 to indicate distinct procedure If the same tool is used more than once, i.e., ADHD tool for teacher and parent: Use modifier -76 to indicate same procedure, same day **(Some payers will only accept the modifier 59 with multiple screens or may require that you report multiple screens in units, ie, X 2) Tennessee Chapter of the American Academy of Pediatrics 63

99420 – Administration and interpretation of health risk assessment instrument (eg, health hazard appraisal) Must be scored and results documented! Examples of health risk assessments include but are not limited to:  EPDS  CRAFFT Tennessee Chapter of the American Academy of Pediatrics 64

The AAP now recommends reporting CPT code for the Edinburgh Postnatal Depression Scale (EPDS), recognizing the Edinburgh scale as a measure for risk in the infant’s environment The EPDS is to be appropriately billed at the infant’s visit under the mother’s ID number until the infant receives their on ID number Tennessee Chapter of the American Academy of Pediatrics 65

The CRAFFT is recommended for screening for Alcohol and Drug Use Assessment The CRAFFT may be reported with If the CRAFFT is positive and a brief intervention service is also performed, report instead (Do not report in addition to 99408) Tennessee Chapter of the American Academy of Pediatrics 66

In order to report or 99420, the medical record must include: The screening tool The tool must be completed and scored Physician or provider signature Use modifier –25 with E/M The Tennessee Chapter of the American Academy of Pediatrics67

CodeFee 96110$ $10.54 Tennessee Chapter of the American Academy of Pediatrics 68

Contact information: Janet Smith, Coding Educator Phone: Please visit our Tennessee Chapter of the American Academy of Pediatrics 69