CBHC 2013 CPT Code Changes, HandOUT 2, Version 1.



Cheat Sheet for MHC and BHO Information Systems (IS)SUBMITTING ENCOUNTERS/CLAIMS FOR NEW CODES, CURRENT STATUSFor 837s, the 5010 X12 standard already allows for multiple services to be reported within the same “claim loop”.? For example, a hospital can (and typically does) bill multiple services for the same client, on the same day (but with different procedure codes) under the same claim number. It is possible that we can do the same for primary service codes + add-on codes using the same claim number, if the State desires it. However, it is also possible that the State can continue to receive services with distinct claim numbers. We should seek instructions/direction from the State, just as we would with any other payer.For the Flat File, which is a HCPF-derived standard, we need to wait for directions/instructions from HCPF on how to proceed differently (if at all). It is possible that the current Flat File can accommodate the 2013 CPT code changes without any modification.***The CBHC Coding Subcommittee has met with HCPF to sort out these processes. We will provide answers as soon as we receive them***NEW CONCEPTSEvaluation and Management codes (E&M): These are codes that specifically begin with 99. The specific E&M code that a prescriber picks and will be billed depends on three major components:HistoryExaminationMedical Decision Making In addition, the level of service also determines the correct E&M code to be picked.Add on codes: Add on codes allow for showing additional work done on a primary service code. E.g., Psychotherapy done by a prescriber in addition to medication management.When billing a primary code with additional related (add-on) codes, the primary code and the additional add-on code(s) must appear on the same claim. The primary code MUST appear on the claim first preceding the add-on codes. Add-on codes are reimbursable services when reported in addition to the appropriate primary service by the same individual physician or other health care professional. Add-on codes reported as stand-alone codes are not reimbursable services in accordance with Current Procedural Services (CPT?) and the Centers for Medicare and Medicaid (CMS) guidelines. The primary code and add-on codes must be billed by the same individual physician or other health care professional reporting under the same Federal Tax Identification number. Add-on procedures must be reported with the primary procedure for the same date of service.CODE CHANGES SUMMARYDeleted Codes9080190802908049080590806908079080890809908109081190812908139081490815908169081790818908199082190822908239082490825908269082790828908299085790862New Codes907919079290832908349083790839E&M Codes used for Medication Management or in conjunction with psychotherapyOffice or Other outpatient Visit/ConsultationsNursing HomeHospital Services/Inpatient consultationsRest Home, boarding home, Custodial Care9920199202992039920499205992119921299213992149921599241992429924399244992459930499305993069930799308993099931099315993169931899217992189921999220992249922599226992319923299233992349923599236992389923999251 99252 99253 99254 9925599366993679936899441 994429944399337993419934299343993449934599347993489934999350993249932599326993279932899334993359933699337New Add-on codes+90785, Interactive Complexity +90833, 30-minute psychotherapy add-on code. Can be combined with any E&M code+90836, 45-minute psychotherapy add-on code. Can be combined with any E&M code+90838, 60-minute psychotherapy add-on code. Can be combined with any E&M code+90840, 30-minute psychotherapy for crisis add-on code. To be used with crisis code 90839 as needed.+99354 to +99357, Add on codes for prolonged services-DO NOT USE YETChanges in two existing codes90875, Duration changed to 30 minutes90876, Duration changed to 45 minutesPossible CPT Primary and Add On Code Combinations Allowed for Billing for Frequently Used Codes. Follow similar logic for other E&M codes 999201-99255, 99304-99337, 99341-99350 when using Add on code 90785Exceptions: Do not report 90875 in conjunction with 90839, 90840, or in conjunction with E/M services when no psychotherapy service is reported. Evaluation and Management (Outpatient, New patient)Evaluation and Management (Outpatient, Established)Evaluation and Management (Inpatient)PsychotherapyPsychotherapy during crisisGroup PsychotherapyPsychiatric Diagnostic Evaluation99201...or…99201 + 9083399201 + 9083699201 + 9083899201 + 90833 + 9078599201 + 90836 + 9078599201 + 90838 + 9078599202...or…99202 + 9083399202 + 9083699202 + 9083899202 + 90833 + 9078599202 + 90836 + 9078599202 + 90838 + 9078599203...or…99203 + 9083399203 + 9083699203 + 9083899203 + 90833 + 9078599203 + 90836 + 9078599203 + 90838 + 9078599204...or…99204 + 9083399204 + 9083699204 + 9083899204 + 90833 + 9078599204 + 90836 + 9078599204 + 90838 + 9078599205…or…99205 + 9083399205 + 9083699205 + 9083899205 + 90833+9078599205 + 90836+9078599205 + 90838+9078599211…or…99211 +9083399211+9083699211+ 9083899211 +90833+9078599211+ 90836+9078599211+ 90838+9078599212…or…99212 +9083399212+9083699212+ 9083899212 +90833+9078599212+ 90836+9078599212+ 90838+9078599213…or…99213 +9083399213+9083699213+ 9083899213 +90833+9078599213+ 90836+9078599213+ 90838+9078599214…or…99214+9083399214+9083699214+9083899214+90833+9078599214+90836+9078599214+90838+9078599215…or…99215+9083399215+9083699215+9083899215+90833+9078599215+90836+9078599215+90838+9078599221…or…99221+9083399221+9083699221+9083899221+90833+9078599221+90836+9078599221+90838+9078599222…or…99222+9083399222+9083699222+9083899222+90833+9078599222+90836+9078599222+90838+9078599223…or…99223+9083399223+9083699223+9083899223+90833+9078599223+90836+9078599223+90838+9078599231…or…99231+9083399231+9083699231+9083899231+90833+9078599231+90836+9078599231+90838+9078599232…or---99232+9083399232+9083699232+9083899232+90833+9078599232+90836+9078599232+90838+9078599233…or…99233+9083399233+9083699233+9083899233+90833+9078599233+90836+9078599233+90838+9078590832…or…90832+9078590834…or…90834+9078590837…or90837+9078590839…or…90839+9084090839+90840+90840+…etc. (e.g., you can keep adding more ‘90840’s to cover the time you spent withthis session)90853…or…90853+9078590791…or…90791+9078590792…or…90792+90785USING AND CODING E&M CODESChoosing an appropriate E&M codes involves a variety of categories and levels of care. Prescribers are being trained on how to use these codes. To help IS code these combinations of categories and levels of care, we are proving you with cross tables. These tables are simple and only serve as a reference document. Clinicians and IS teams will need to work together to make the system configuration process meaningful.Outpatient Office Visits E&M codes*Shows the number of the three key components: Exam, History, and Medical decision making needed to bill the codeCodeType History?Exam??Medical Decision-MakingTimeProblem FocusedExtended Problem FocusedDetailedComprehensiveProblem FocusedExtended Problem FocusedDetailedComprehensiveStraightforwardLow complexityModerate ComplexityHigh ComplexityAvg. Time99201New Patient Office or other outpatient Visit *Requires 3 of 3 X???X???X???10 MIN99202New Patient Office or other outpatient Visit *Requires 3 of 3 ?X???X??X???20 MIN99203New Patient Office or other outpatient Visit *Requires 3 of 3 ??X???X??X??30 MIN99204New Patient Office or other outpatient Visit *Requires 3 of 3 ???X???X??X?45 MIN99205New Patient Office or other outpatient Visit *Requires 3 of 3 ???X???X???X60 MIN99212Established Patient Office or Outpatient Visit **Requires 2 of 3X???X???X???10 MIN99213Established Patient Office or Outpatient Visit **Requires 2 of 3?X???X???X??15 MIN99214Established Patient Office or Outpatient Visit **Requires 2 of 3??X???X???X?25 MIN99215Established Patient Office or Outpatient Visit **Requires 2 of 3???X???X???X40 MINInpatient, Nursing Home, Rest Home, Boarding Home, Custodial Care E&M codes*Shows the number of the three key components: Exam, History, and Medical decision making needed to bill the codeCodeType HistoryExamMedical Decision-MakingTimeProblem FocusedExtended Problem FocusedDetailedComprehensiveProblem FocusedExtended Problem FocusedDetailedComprehensiveStraightforwardLow complexityModerate ComplexityHigh ComplexityAvg. Time INITIAL INPATIENT CARE99221Initial Inpatient Hospital Care. New or established patient. * Requires 3 of 3??X???X?XX??3099222Initial Inpatient Hospital Care. New or established patient. * Requires 3 of 3???X???X??X?5099223Initial Inpatient Hospital Care. New or established patient. * Requires 3 of 3???X???X???X70 SUBSEQUENT INPATIENT CARE99231Subsequent Hospital Care. New or established patient. **Requires 2 of 3X???X???XX??1599232Subsequent Hospital Care. New or established patient. **Requires 2 of 3?X???X????X?2599233Subsequent Hospital Care. New or established patient. **Requires 2 of 3??X???X????X35 INITIAL OBSERVATION CARE99218Initial Observation Care. New or established patient. * Requires 3 of 3??XX??XXXX??3099219Initial Observation Care. New or established patient. * Requires 3 of 3???X???X??X?5099220Initial Observation Care. New or established patient. * Requires 3 of 3???X???X???X70 SUBSEQUENT OBSERVATION CARE99224Subsequent Observation Care. New or established patient. *Requires 2 of 3.X???X???XX??1599225Subsequent Observation Care. New or established patient. *Requires 2 of 3.?X???X????X?2599226Subsequent Observation Care. New or established patient. *Requires 2 of 3.??X???X????X35 OBSERVATION OR INPATIENT CARE ADMIT & DC SAME DAY99234Observation or Inpatient Care including admit and discharge on same day. New or established patient. *Requires 3 of 3??X???X?XX??NA99235Observation or Inpatient Care including admit and discharge on same day. New or established patient. *Requires 3 of 3???X???X??X?NA99236Observation or Inpatient Care including admit and discharge on same day. New or established patient. *Requires 3 of 3???X???X???XNA INITIAL NURSING HOME CARE99304Initial Nursing Facility Care. New or established patient. *Requires 3 of 3.??X???X?XX??2599305Initial Nursing Facility Care. New or established patient. *Requires 3 of 3.???X???X??X?3599306Initial Nursing Facility Care. New or established patient. *Requires 3 of 3.???X???X???X45 SUBSEQUENT NURSING HOME CARE99307Subsequent Nursing Facility Care. New or established patient. *Requires 2 of 3.X???X???X???1099308Subsequent Nursing Facility Care. New or established patient. *Requires 2 of 3.?X???X???X??1599309Subsequent Nursing Facility Care. New or established patient. *Requires 2 of 3.??X???X???X?2599310Subsequent Nursing Facility Care. New or established patient. *Requires 2 of 3.???X???X???X35NURSING HOME DISCHARGE OR ANNUAL REVIEW99315Nursing Facility Discharge 30 minutes or less????????????30 or <3099316Nursing Facility Discharge >30 minutes????????????>3099318Annual Nursing Facility Assessment*Requires 3 of 3??X?????X?XX30 REST HOME, BOARDING HOME, CUSTODIAL CARE99324Rest Home, Boarding Home, Custodial Care. New patient. *Requires 3 of 3.X???X???X???2099325Rest Home, Boarding Home, Custodial Care. New patient. *Requires 3 of 3.?X???X???X??3099326Rest Home, Boarding Home, Custodial Care. New patient. *Requires 3 of 3.??X???X???X?4599327Rest Home, Boarding Home, Custodial Care. New patient. *Requires 3 of 3.???X???X??X?6099328Rest Home, Boarding Home, Custodial Care. New patient. *Requires 3 of 3.???X???X???X7599334Rest Home, Boarding Home, Custodial Care. Established patient. *Requires 3 of 3.X???X???X???1599335Rest Home, Boarding Home, Custodial Care. Established patient. *Requires 3 of 3.?X???X???X??2599336Rest Home, Boarding Home, Custodial Care. Established patient. *Requires 3 of 3.??X???X???X?4099337Rest Home, Boarding Home, Custodial Care. Established patient. *Requires 3 of 3.???X???X???X60 EXAMPLE FROM MHCD, DRAFT CODING FOR E&M SERVICESPlease note: Some MHCs have requested an example of how to code E&M codes in their EMRs. MHCD is sharing their draft coding. Please make sure to check the 2013 CPT code book for accuracy.START EMCodingQuestions(parmfile, option, client, retcode)parmfile is x, option is x, client is x, retcode is x $allowupdate(retcode)sCPT is x bNewPatient is b sPctCounseling is xsPctCoordination is x tDuration is t iHistory is i '1 = Problem-focused, 2 = Expanded Px focused, 3 = detailed, 4 = comprehensiveiExam is i '1 = Problem-focused, 2 = Expanded Px focused, 3 = detailed, 4 = comprehensiveiComplexity is i '1 = straightforward, 2 = low, 3 = moderate, 4 = highiPresentingPx is i'1 = minimal, 2 = minor, 3 = low, 4 = moderate, 5 = high%define kTitle "E/M Supplemental Questions"%define true 1%define false 0rc is i EnterData(client, bNewPatient, tDuration, sPctCounseling, sPctCoordiation, iHistory, iExam, iComplexity, iPresentingPx)sCPT = ComputeEM(bNewPatient, tDuration, sPctCounseling, sPctCoordiation, iHistory, iExam, iComplexity, iPresentingPx)'Note, in order to be useful, this program should then do something with the CPT code that is calculated.END EMCodingQuestions''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''dynamic function EnterData(sConsumer, bNewPatient, tDuration, sPctCounseling, sPctCoordiation, iHistory, iExam, iComplexity, iPresentingPx) is nullsConsumer is x bDone is b bNewPatient is b sPctCounseling is xsPctCoordination is x tDuration is t iHistory is i '1 = Problem-focused, 2 = Expanded Px focused, 3 = detailed, 4 = comprehensiveiExam is i '1 = Problem-focused, 2 = Expanded Px focused, 3 = detailed, 4 = comprehensiveiComplexity is i '1 = straightforward, 2 = low, 3 = moderate, 4 = highiPresentingPx is i'1 = minimal, 2 = minor, 3 = low, 4 = moderate, 5 = highsErrorMsg is x $allowupdate(bNewPatient, tDuration, sPctCounseling, sPctCoordiation, iHistory, iExam, iComplexity, iPresentingPx)bDone = falsedo until bDone = true$form()$tag("<center>")$text(kTitle, "H1")$br(2)if sErrorMsg dp then$text(sErrorMsg, "error")endif$table(1)$row()$col()$text("Consumer status*", "datatag") $br()$radio(bNewPatient, "New", true) $br()$radio(bNewPatient, "Established", false)$col()$text("Duration of E/M encounter*", "datatag") $br()$textbox(tDuration, "DUR", 5, 5)$row()$col()$text("Percent of encounter devoted to counseling*", "datatag") $br()$textbox(sPctCounseling,,3,3) 'note, it would be really nice if there were a numeric edit available for textboxes...$col()$text("Percent of encounter devoted to coordination of care*", "datatag") $br()$textbox(sPctCoordination,,3,3)$row()$col()$text("Extent of history obtained*")$dropbox(iHistory, "Problem-focused", 1)$dropbox(iHistory, "Expanded problem-focused", 2)$dropbox(iHistory, "Detailed", 3)$dropbox(iHistory, "Comprehensive", 4)$col()$text("Extent of examination performed*")$dropbox(iExam, "Problem-focused", 1)$dropbox(iExam, "Expanded problem-focused", 2)$dropbox(iExam, "Detailed", 3)$dropbox(iExam, "Comprehensive", 4)$row()$col()$text("Complexity of medical decision making*")$dropbox(iComplexity, "Straightforward", 1)$dropbox(iComplexity, "Low", 2)$dropbox(iComplexity, "Moderate", 3)$dropbox(iComplexity, "High", 4)$col()$text("Nature of the presenting problem*")$dropbox(iPresentingPx, "Minimal", 1)$dropbox(iPresentingPx, "Self-limited or minor", 2)$dropbox(iPresentingPx, "Low severity", 3)$dropbox(iPresentingPx, "Moderate severity", 4)$dropbox(iPresentingPx, "High serverity", 4)$endtable(1)$tag("</center>")$sendform()$clear(sErrorMsg)bDone = "libNTExtra":ValidateEM(sConsumer, bNewPatient, tDuration, sPctCounseling, sPctCoordiation, iHistory, iExam, iComplexity, iPresentingPx, sErrorMsg)enddoend EnterData''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''dynamic function ComputeEM(bNewPatient, tDuration, sPctCounseling, sPctCoordiation, iHistory, iExam, iComplexity, iPresentingPx) is x bNewPatient is b sPctCounseling is xsPctCoordination is x tDuration is t iHistory is i '1 = Problem-focused, 2 = Expanded Px focused, 3 = detailed, 4 = comprehensiveiExam is i '1 = Problem-focused, 2 = Expanded Px focused, 3 = detailed, 4 = comprehensiveiComplexity is i '1 = straightforward, 2 = low, 3 = moderate, 4 = highiPresentingPx is i'1 = minimal, 2 = minor, 3 = low, 4 = moderate, 5 = highiPctCounseling is i iPctCoordination is i iPctBoth is i iPctCounseling = $casti(sPctCounseling) iPctCoordination = $casti(sPctCoordination) iPctBoth = iPctCounseling + iPctCoordination select bNewPatientcase trueif iPctBoth > 50 then 'when Counseling and Coordination > 50% of session, E/M is time-basedselect tDurationcase >= 53ComputeEM = "99205"case >= 38ComputeEM = "99204"case >= 25ComputeEM = "99203"case >= 15ComputeEM = "99202"case otherComputeEM = "99201"endselect elseselect iHistorycase 4 select iExamcase 4 select iComplexitycase 4 ComputeEM = "99205" 'History 4, Exam 4, Complexity 4case 3 ComputeEM = "99204" 'History 4, Exam 4, Complexity 3case 2 ComputeEM = "99203" 'History 4, Exam 4, Complexity 2 case 1 ComputeEM = "99202" 'History 4, Exam 4, Complexity 1 endselectcase 3 select iComplexitycase >= 2 ComputeEM = "99203" 'History 4, Exam 3, Complexity >= 2case 1 ComputeEM = "99202" 'History 4, Exam 3, Complexity = 1 endselectcase 2 ComputeEM = "99202" 'History 4, Exam 2, Complexity anycase 1 ComputeEM = "99201"'History 4, Exam 1, Complexity anyendselectcase 3 select iExamcase >= 3 select iComplexitycase >= 2 ComputeEM = "99203" 'History 3, Exam >= 3, Complexity >= 2case 1 ComputeEM = "99202" 'History 3, Exam >= 3, Complexity 1endselectcase 2 ComputeEM = "99202" 'History 3, Exam 2, Complexity anycase 1 ComputeEM = "99201"'History 3, Exam 1, Complexity anyendselectcase 2 if iExam >= 2 thenComputeEM = "99202" 'History 2, Exam >= 2, Complexity anyelseComputeEM = "99201" 'History 2, Exam 1, Complexity anyendifcase 1 ComputeEM = "99201" 'History 1, Exam any, Complexity anyendselectendif'Existing Patient Logiccase falseif iPctBoth > 50 then 'when Counseling and Coordination > 50% of session, E/M is time-basedselect tDurationcase >= 33ComputeEM = "99215"case >= 20ComputeEM = "99214"case >= 13ComputeEM = "99213"case >= 8ComputeEM = "99212"case otherComputeEM = "99211"endselect elseselect iHistorycase 4 if iExam = 4 or iComplexity = 4 thenComputeEM = "99215"elseif iExam = 3 or iComplexity = 3 thenComputeEM = "99214"elseif iExam = 2 or iComplexity = 2 thenComputeEM = "99213"elseComputeEM = "99212"endifcase 3 if iComplexity = 4 and iExam = 4 thenComputeEM = "99215"elseif iComplexity >= 3 or iExam >= 3 thenComputeEM = "99214"elseif iComplexity = 2 or iExam = 2 thenComputeEM = "99213"else ComputeEM = "99212"endifcase 2 if iComplexity = 4 and iExam = 4 thenComputeEM = "99215"elseif iComplexity >= 3 and iExam >= 3 thenComputeEM = "99214"elseif iComplexity >= 2 or iExam >= 2 thenComputeEM = "99213"else ComputeEM = "99212"endifcase 1if iComplexity = 4 and iExam = 4 thenComputeEM = "99215"elseif iComplexity >= 3 and iExam >= 3 thenComputeEM = "99214"elseif iComplexity >= 2 and iExam >= 2 thenComputeEM = "99213"else ComputeEM = "99212"endselectendifendselectend ComputeEM ................
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