1. 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

2. 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.

3. 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

4. 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 99381 Age < 1 year 99382 Ages 1 – 4 years 99383 Ages 5 – 11 years 99384 Ages 12 – 17 years 99385 Ages 18 – 39 years Tennessee Chapter of the American Academy of Pediatrics 4

5. 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 99391 Age < 1 year 99392 Ages 1 – 4 years 99393 Ages 5 – 11 years 99394 Ages 12 – 17 years 99395 Ages 18 – 39 years Tennessee Chapter of the American Academy of Pediatrics 5

6. 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

7. New Patients 99201 – Straightforward, 10 minutes 99202 – Straightforward, 20 minutes 99203 - Low, 30 minutes 99204 - Moderate, 45 minutes 99205 - High, 60 minutes Tennessee Chapter of the American Academy of Pediatrics 7

8. Established Patients 99211 – Nurse visit, 5 minutes 99212 - Straightforward, 10 minutes 99213 – Low, 15 minutes 99214 – Moderate, 25 minutes 99215 – High, 40 minutes Tennessee Chapter of the American Academy of Pediatrics 8

9. If the provider is spending at least 25 minutes with the patient and over 50% of that time is counseling and coordinating care, 99214 can be reported. Provider must document time and describe the counseling/care coordination provided Tennessee Chapter of the American Academy of Pediatrics 9

10. 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

11. 99214 = 25 minutes 99215 = 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 99215 because the time falls closer to 40 minutes than 25 minutes. Tennessee Chapter of the American Academy of Pediatrics 11

12. CodeTypical TimeMinimum Time 9920110 minN/A 9920220 min16 min 9920330 min26 min 9920445 min38 min 9920560 min53 min 992115 minN/A 9921210 min8 min 9921315 min13 min 9921425 min21 min 9921540 min33 min Tennessee Chapter of the American Academy of Pediatrics 12

13. CodeMC 2013 FeeDifference (from previous level) 99212$42.52 99213$70.63$28.11 99214$104.02$33.39 99215$139.77$35.75 Tennessee Chapter of the American Academy of Pediatrics 13

14. 99354 and 99355 - 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

15. 99354 - reported for prolonged service of 30 to 74 minutes 99355 – reported for each additional 30 minutes beyond the first hour Tennessee Chapter of the American Academy of Pediatrics 15

16. 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 – 99215 (40 minutes average time) Prolonged service 30 minutes - 99354 Tennessee Chapter of the American Academy of Pediatrics 16

17. CodeFee 99215$139.77 99354 $95.87 Total = $235.64 For each additional 30 minutes: CodeFee 99355$93.60 Tennessee Chapter of the American Academy of Pediatrics 17

18. 99358 and 99359 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

19. ● 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

20. ● 99358 and 99359 are used to report the total duration of non face-to-face time providing prolonged service, even if the time is not continuous ● 99358 should only be used once per date for the first hour of prolonged service ● 99359 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

21. ● Do not report 99358 and 99359 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

22. 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 99358 Tennessee Chapter of the American Academy of Pediatrics 22

23. CodeFee 99358 $105.09 For each additional 30 minutes: CodeFee 99359 $50.95 Tennessee Chapter of the American Academy of Pediatrics 23

24. Total Duration of Prolonged Services Code(s) less than 30 minutesNot reported separately 30-74 minutes (1/2 hr. - 1 hr. 14 min.) 9935499354 X 1 or 99358 X 1 75-104 (1 hr. 15 min. - 1 hr. 44 min.) 9935499354 X 1 and 99355 X 1 or99355 99358 X 1 and 99359 X1 105 or more (1 hr. 45 min. or more) 9935499354 X 1 and 99355 X 2 or99355 99358 X 1 and 99359 X 2 or more for each additional 30 minutes Tennessee Chapter of the American Academy of Pediatrics 24

25. 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

26. Regular office hours are M-F 8:00 am - 5:00 pm Patient is seen at 6:00 pm Report E/M and 99050:  99213  99050 Tennessee Chapter of the American Academy of Pediatrics 26

27. 99051 - 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

28. Regular office hours are 8:00 to 12:00 on Saturday Patient is seen at 9:00 on Saturday Report E/M service and 99051 ie:  99214  99051 Tennessee Chapter of the American Academy of Pediatrics 28

29. 99050 and 99051 do not have established RVUs Typical Reimbursement range for 99050: $15.00 - $30.00 Most payers do not reimburse for 99051 (**You may be able to negotiate with payers to use 99050 for “posted after-hours care”) Tennessee Chapter of the American Academy of Pediatrics 29

30. 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

31. 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

32. 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

33. 99339 – Individual physician supervision of a patient (patient not present) in home …15 -29 minutes 99340 - >30 minutes Tennessee Chapter of the American Academy of Pediatrics 33

34. 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 99340 Tennessee Chapter of the American Academy of Pediatrics 34

35. CodeFee 99340$105.20 Care plan oversight 99340 billed for 12 months = $1,262.40 per patient! Tennessee Chapter of the American Academy of Pediatrics 35

36. 99374 – Physician supervision of a patient under care of a home health agency (patient not present) in home, domiciliary, or equivalent environment….15-29 minutes 99375 - >30 minutes Tennessee Chapter of the American Academy of Pediatrics 36

37. 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 99375 Tennessee Chapter of the American Academy of Pediatrics 37

38. CodeFee 99375$101.59 Care plan oversight 99375 billed for 12 months = $1,219.08 per patient! Tennessee Chapter of the American Academy of Pediatrics 38

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

40. 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

41. ● 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

42. ● 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

43. 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 99488 – 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 +99489 – 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

44. ● 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

45. 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 99487 Tennessee Chapter of the American Academy of Pediatrics

46. 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 99488 Tennessee Chapter of the American Academy of Pediatrics

47. Complex Care Coordination 99487 = $79.91 99488 = $179.27 (with face-to-face visit) 99489 = $40.12 Tennessee Chapter of the American Academy of Pediatrics

48. ● 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

49. ● 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

50. 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

51. 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 99496 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

52. ● 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

53. 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

54. 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 99495 Tennessee Chapter of the American Academy of Pediatrics

55. 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 99496 Tennessee Chapter of the American Academy of Pediatrics

56. Transitional Care Management (TCM) 99495 = $159.85 99496 = $225.35 Tennessee Chapter of the American Academy of Pediatrics 56

57. Tennessee Chapter of the American Academy of Pediatrics

58. 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

59. 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

60. Recommended Screenings: Developmental Screening 9, 18 and 30 months Autism Screening 18 and 24 months Depression Screening (*New) 11-21 years Alcohol and Drug use Assessment 11-21 years Tennessee Chapter of the American Academy of Pediatrics 60

61. 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

62. 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

63. 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, 96110 X 2) Tennessee Chapter of the American Academy of Pediatrics 63

64. 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

65. The AAP now recommends reporting CPT code 99420 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

66. The CRAFFT is recommended for screening for Alcohol and Drug Use Assessment The CRAFFT may be reported with 99420 If the CRAFFT is positive and a brief intervention service is also performed, report 99408 instead (Do not report 99420 in addition to 99408) Tennessee Chapter of the American Academy of Pediatrics 66

67. In order to report 96110 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

68. CodeFee 96110$9.86 99420$10.54 Tennessee Chapter of the American Academy of Pediatrics 68

69. Contact information: Janet Smith, Coding Educator Email: janet.smith@tnaap.orgjanet.smith@tnaap.org Phone: 615-447-3264 Please visit our website @ www.tnaap.orgwww.tnaap.org Tennessee Chapter of the American Academy of Pediatrics 69