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v1 Palliative Operational Coding

This document discusses coding for palliative care physician services. It covers evaluation and management codes, medical decision making criteria, and how to set up a fee schedule in Axxess Palliative Care to select appropriate codes at the end of a visit.

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38 views2 pages

v1 Palliative Operational Coding

This document discusses coding for palliative care physician services. It covers evaluation and management codes, medical decision making criteria, and how to set up a fee schedule in Axxess Palliative Care to select appropriate codes at the end of a visit.

Uploaded by

sundayjabikem
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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2023

Physician Services Coding

If your organization bills for palliative services based on a fee for service professional fee schedule
understanding coding and the documentation required to support, it are imperative to your
organizations cash flow. Clinicians limited to fee for service reimbursement are limited at the payer
level. For Medicare this could be physical therapy, providers, or social work services. Commercial
insurances may also cover mental or behavior health services.

Today we will review coding from the perspective of a provider. Palliative care visits can be provided
and billed as evaluation and management (E/M) by physicians, nurse practitioners, clinical nurse
specialists, and physician assistants.

Office or other outpatient services include a medically appropriate history and/or physical
examination, when performed. The nature and extent of the history and/or physical examination
are determined by the treating physician or other qualified health care professional reporting the
service. The care team may collect information and the patient or caregiver may supply information
directly (eg, by electronic health record [EHR] portal or questionnaire) that is reviewed by the
reporting physician or other qualified health care professional.

Procedure and service codes are published by the American Medical Association in Current
Procedural Terminology and CPT Book for Guidance. In a 2021 update to the Evaluation and
Management office, outpatient, and prolonged services code and guideline change CMS changed
the definitions for time associated with a visit and introduced the ability to bill based off of time or
the complexity of a visit.

For office or other outpatient services codes 99341, 99342, 99344, 99345, 99347-99350 the time for
these services is the total time on the date of the encounter. It includes both the face-to-face and
non-face-to-face time personally spent by the physician and/or other qualified health care
professional(s) on the day of the encounter (includes time in activities that require the physician or
other qualified health care professional and does not include time in activities normally performed
by clinical staff).

Professional interpretation of tests or studies ordered, that are not results only tests, should be
billed separately form an encounter.

Medical Decision Making (MDM) is an alternative way to determine what code to use from time-
based codes. There are three factors in determining medical decision making.
• Number and complexity of problems
• The amount and complexity of data to be reviewed and analyzed.
• Risk of complications and or morbidity/mortality of patient management

Each of these categories has intensive thresholds and criteria to determine if they fall into the
following categories.
• Straightforward
• Low Complexity
2023

• Moderate Complexity
• High Complexity

To determine the medical decision-making complexity of a visit 2 of the 3 factors must meet an
MDM category. For example, if the number and complexity of problems is a low complexity but the
amount and complexity of data to be reviewed and analyzed is Moderate and the Risk of
complications and or morbidity/mortality is also moderate then the visit meets the criteria for
Moderate complexity.

Coding is complex and highly subject to the way in which you run your organization. Be sure to
understand your organization's payer requirements and how they prefer that coding is
accomplished.

Let’s take a look at how CPT codes are displayed to a user at the end of a visit. Given that a visit is
associated with payer that has a professional services fee schedule associated to it that specific visit,
your organization can create a CPT code fee schedule that meets your specific patient population
needs. This fee schedule also has automated logic built in to recognize your patients place of service
and provide you with the right codes based on the visit.

In Axxess Palliative Care, the Fee Schedule is divided into 3 areas:


• Provider Fee Schedule for routine visit types are entered.

These codes are your primary evaluation and management codes.


o Example: 99341: for the evaluation and management of a new patient, which
requires a medically appropriate history and/or examination and straightforward
medical decision making. When using total time on the date of the encounter for
code selection, 15 minutes must be met or exceeded.
• Prolonged Codes:

These codes are used for any long visits when billing based on time. Axxess palliative
care has logic that can be setup at the payer level to help you calculate your prolonged visit codes.
o Example: 99358: first hour of prolonged service on a given date regardless of the
place of service.
• Other Visits:
o Other codes are potential additional codes that can be added to
your visits and must be selected by the user at the end of the visit. Example: 99497:
Advanced Care Planning Additional 30 minutes

After the Fee Schedule is created, providers can select correct options for coding when completing
the visit. Axxess Palliative Care Solution has built-in intelligence to support accurate coding.

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