Clinical Example for Critical Care

Clinical Examples - Critical care services

An 85-year-old male patient is admitted to the intensive care unit following abdominal aortic aneurysm resection. Two days after surgery he requires fluids and pressors to maintain adequate perfusion and arterial pressures. He remains ventilator-dependent.

A 66-year-old female patient is 4 days status post mitral valve repair. She develops petechiae, hypotension, and hypoxia requiring respiratory and circulatory support.

A 72-year-old male admitted for right lower lobe pneumococcal pneumonia with a history of COPD becomes hypoxic and hypotensive 2 days after admission.

A 58-year-old admitted for an acute anterior wall myocardial infarction continues to have symptomatic ventricular tachycardia that is marginally responsive to antiarrhythmic therapy

Clinical Examples - Non Covered Critical care services

The Patients admitted to a critical care unit because no other hospital beds were available.

The Patients admitted to a critical care unit for close nursing observation and/or frequent monitoring of vital signs (e.g., drug toxicity or overdose).

The Patients admitted to a critical care unit because hospital rules require certain treatments (e.g., insulin infusions) to be administered in the critical care unit.

Example: 

A dermatologist evaluates and treats a rash on an ICU patient who is maintained on a ventilator and nitroglycerine infusion that is being managed by an intensive visit. The dermatologist should not report service for critical care.

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New Lab Codes Effective July 1, 2021

The New HCPCS Lab Codes are released which is Effective from July 1, 2021. These new codes are contractor-priced (where applicable) until they are nationally priced and undergo the CLFS annual payment determination process. 

The MACs will only price PLA codes for laboratories within their jurisdiction. and Type of Service (TOS) for all the codes should be "5".

0248U - Oncology (brain), spheroid cell culture in a 3D microenvironment, 12 drug panel, tumor-response prediction for each drug.

0249U - Oncology (breast), semiquantitative analysis of 32 phosphoproteins and protein analytes, includes laser capture microdissection, with algorithmic analysis and interpretative report.

0250U - Oncology (solid organ neoplasm), targeted genomic sequence DNA analysis of 505 genes, interrogation for somatic alterations (SNVs [single nucleotide variant], small insertions and deletions, one amplification, and four translocations), microsatellite instability and tumor-mutation burden.

0251U - Hepcidin-25, enzyme-linked immunosorbent assay (ELISA), serum or plasma.

0252U - Fetal aneuploidy short tandem–repeat comparative analysis, fetal DNA from products of conception, reported as normal (euploidy), monosomy, trisomy, or partial deletion/duplications, mosaicism, and segmental aneuploidy.

0253U - Reproductive medicine (endometrial receptivity analysis), RNA gene expression profile, 238 genes by nextgeneration sequencing, endometrial tissue, predictive algorithm reported as endometrial window of implantation (eg, pre-receptive, receptive, post-receptive).

0254U - Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using embryonic DNA genomic sequence analysis for aneuploidy, and a mitochondrial DNA score in euploid embryos, results reported as normal (euploidy), monosomy, trisomy, or partial deletion/duplications, mosaicism, and segmental aneuploidy, per embryo tested.

G0327 - Colorectal cancer screening; blood-based biomarker.

Critical Care Guidelines - CPT 99291 and 99292

Critical care is the direct delivery by a physician(s) or other qualified health care professional of medical care for a critically ill or critically injured patient.

A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition. 

Critical care services include the treatment of vital organ failure or prevention of further life-threatening conditions. 

Delivering medical care in a moment of crisis and in time of emergency is not the only requirement for providing Critical Care services.

Examples of vital organ system failure include, but are not limited to,

• Central nervous system failure, 
• Circulatory failure, 
• Shock, 
• Renal, hepatic, metabolic, and/or respiratory failure. 

Critical care may be provided on multiple days, even if no changes are made in the treatment rendered to the patient, provided that the patient's condition continues to require the level of attention mentioned above.

Key Points

The Critical Care Services for a patient who is not critically ill but happens to be in a critical care unit are reported using other appropriate E/M codes.

Critical care and other E/M services may be reported to the same patient on the same date by the same individual.

The critical care code is applicable for a critical care service provided for the first 30 – 74 minutes. Any Critical Care service provided for less than 30 minutes should be billed with the appropriate level of E/M code.

Usually, a Critical Care service is provided to a patient in a "Critical Care Area" such as,

• Coronary Care Unit (CCU), 
• Intensive Care Unit (ICU), 
• Respiratory Care Unit, or 
• Emergency Room.

Included Services

The mentioned below list of services are included when performed during the "Critical Care service"

• Interpretation of cardiac output measurements - 93561, 93562
• Chest X rays -71045, 71046
• Pulse oximetry - 94760, 94761, 94762[blood gases, and collection and interpretation of physiologic data] (eg, ECGs, blood pressures, hematologic data);
• Gastric intubation - 43752, 43753
• Temporary transcutaneous pacing - 92953 
• Ventilatory management - 94002-94004, 94660, 94662 
• Vascular access procedures - 36000, 36410, 36415, 36591, 36600

Any services performed that are not included in this listing should be reported separately. Facilities may report the above services separately.

Tips

Inpatient critical care services provided to neonates (28 days of age or younger) are reported with the neonatal critical care codes 99468 and 99469. 

Inpatient critical care services provided to infants 29 days through 71 months of age are reported with pediatric critical care codes 99471-99476

To report critical care services provided in the outpatient setting (eg, emergency department or office), for neonates and pediatric patients up through 71 months of age, see the critical care codes 99291, 99292

Click here to check TCM

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Transitional Care Management (TCM) Guidelines

The CPT Codes 99495 and 99496 are used to report transitional care management services (TCM).

These services are covered for a new patient or established patient and the code selection will be considered based on the MDM and the problems require either "Moderate Complexity or High Complexity".

To qualify for Transitional Care Management (TCM) services, the patient must be discharged from one of the following facility settings,

•  Acute Care Hospital
•  Psychiatric Hospital
•  Rehabilitation Facility
•  Long-term Care Hospital
•  Skilled Nursing Facility
•  Partial hospitalization
•  Hospital outpatient observation
•  Partial hospitalization at a community mental health center

Additionally, the patient must be returned to one of the following community settings,

•  Home
•  Domiciliary (e.g., group home or boarding house)
•  Nursing Facility (e.g., boarding home or adult care home)
•  Assisted Living Facility

Guidelines

• TCM is included in one face-to-face visit within the specified time-frames, in combination with non-face-to-face services that may be performed by the physician or other qualified health care professional.

• Only one individual may report these services and only once per patient within 30 days of discharge.

• Another TCM may not be reported by the same individual or group for any subsequent discharge(s) within 30 days.

• The same individual should not report TCM services provided in the postoperative period of a service that the individual reported.

Non-Face To Face Service

Non-face-to-face services provided by the physician or other qualified health care provider may include,

• Obtaining and reviewing the discharge information (eg, discharge summary, as available, or continuity of care documents).

• Reviewing the need for or follow-up on pending diagnostic tests and treatments.

• Interaction with other qualified health care professionals who will assume or reassume care of the patient's system-specific problems.

• Education of patient, family, guardian, and/or caregiver.

• Establishment or reestablishment of referrals and arranging for needed community resources.

• Assistance in scheduling any required follow-up with community providers and services.

The first face-to-face visit is part of the TCM service and not reported separately. 

Additional E/M services provided on subsequent dates after the first face-to-face visit may be reported separately. 

Interactive Communication

For TCM requires interactive contact with the patient or caregiver, as appropriate, within two business days of discharge and the communication typically involves following,

1. In-person visits: Face-to-face visits with the healthcare provider allow for a more comprehensive assessment of the patient's health status and the ability to address any issues that may arise. 
2. Telephone calls: Providers may call patients or caregivers to discuss the patient's condition, medications, follow-up appointments, and any other necessary information.
3. Secure messaging: Some healthcare providers use secure messaging platforms to communicate with patients, allowing for quick and convenient exchange of information.
4. Video visits: Telehealth visits via video conferencing can be used to conduct follow-up visits, assess the patient's progress, and address any concerns.

CPT Codes

• CPT 99496 -The face-to-face visit must occur within 7 calendar days of the date discharge and MDM must be of "High complexity". 

• CPT 99495 -  The face-to-face visit must occur within 14 calendar days of the date of discharge and MDM must be "Moderate complexity".

Documentation

For Transitional Care Management (TCM) services, the following elements must be documented in the patient's record:

1. Date of discharge from acute care
2. Date of provider contact with the patient (two days post-discharge)
3. Date of face-to-face visit with the provider (either 7 days or 14 days post-discharge)
4. Complexity of the Medical Decision Making (MDM), documented as either moderate or high

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Online Digital Evaluation e-visits

Guidelines

• Online digital evaluation and management (E/M) services (99421, 99422, 99423) are patient-initiated services with physicians or other qualified health care professionals (QHPs). 

• It requires a physician or other QHP's evaluation, assessment, and management of the patient. 

• These services are not for the nonevaluative electronic communication of test results, scheduling of appointments, or other communication that does not include E/M. 

• While the patient's problem may be new to the physician or other QHP, the patient is an established patient. 

• Patients initiate these services through Health Insurance Portability and Accountability Act (HIPAA)-compliant secure platforms, such as electronic health record (EHR) portals, secure email, or other digital applications, which allow digital communication with the physician or other QHP.

• Online digital E/M services are reported once for the physician's or other QHP's cumulative time devoted to the service during a seven-day period. 

• Physician's or other QHP's cumulative service time includes a review, Initial inquiry,  review of patient records or data pertinent to an assessment of the patient's problem, 

• The personal physician or other QHP interaction with clinical staff focused, the patient's problem, development of management plans, 

• Including physician- or other QHP generation of prescriptions or ordering of tests, and subsequent communication with the patient through online, telephone, email, or other digitally supported communication, which does not otherwise represent a separately reported E/M service. 

• When the online digital inquiry is related to a surgical procedure and occurs during the postoperative period of a previously completed procedure, then the online digital E/M service is not reported separately. 

• When the patient generates the initial online digital inquiry for a new problem within seven days of a previous E/M visit that addressed a different problem, then the online digital E/M service may be reported separately. 

• When the patient presents a new, unrelated problem during the seven-day period of an online digital E/M service, then the physician's or other QHP's time spent on evaluation, assessment, and management of the additional problem is added to the cumulative service time of the online digital E/M service for that seven-day period.

Physicians

• CPT 99421 - Online digital evaluation and management service, for an established patient, for up to 7 days, a cumulative time during the 7 days; 5-10 minutes

• CPT 99422 - CPT 99421 - Online digital evaluation and management service, for an established patient, for up to 7 days, a cumulative time during the 7 days; 11-20 minutes

• CPT 99423 - CPT 99421 - Online digital evaluation and management service, for an established patient, for up to 7 days, a cumulative time during the 7 days; 21 or more minutes

Non-physicians (NP & PA)

• CPT 98970 - Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, a cumulative time during the 7 days; 5-10 minutes

• CPT 98971 - Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, a cumulative time during the 7 days; 11-20 minutes

• CPT 98972 - Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, a cumulative time during the 7 days; 21 OR more minutes

2021 E&M Changes

COVID - 19 Vaccine Updates - May'2021

The FDA is recommended to use "Pfizer-BioNTech" COVID-19 vaccine for adolescents aged 12-15 years.  

On May 12, 2021, the Advisory Committee on Immunization Practices (ACIP) recommended the use of the "Pfizer-BioNTech" COVID-19 vaccine in adolescents aged 12-15 years, and CDC Director Rochelle Walensky adopted this ACIP recommendation.

All COVID-19 vaccination providers are directed and required to make available and administer COVID-19 vaccine to all persons eligible to receive the COVID-19 vaccine consistent with the applicable Emergency Use Authorizations for such products.   

The COVID-19 vaccines themselves are free to everyone 12 years and older in the United States, but providers incur costs associated with administering them, training staff, and storing the vaccine. 

If these services are not covered by a patient’s health plan or only partially covered, providers are not allowed to balance bill the patients.

Claims for reimbursement will be priced as described below for eligible services,

Vaccine administration fees will be priced based on national Medicare rates for administering the COVID-19 vaccine (not geographically adjusted) and are outlined below,

For dates of service through March 14, 2021:-

• Administration of a single-dose COVID-19 vaccine - $28.39

• Administration of the first dose of a COVID-19 vaccine requiring a series of two or more doses - $16.94

• Administration of the final dose of a COVID-19 vaccine requiring a series of two or more doses - $28.39

For dates of service on or after March 15, 2021:-

• Administration (per dose) of a COVID-19 vaccine - $40.00

• Reimbursement will be based on the incurred date of service.

Click here for COVID-19 Lab Code Updates

Cognitive Assessment and Care Plan - Guidelines

Cognitive assessment and care plan services are provided when a comprehensive evaluation of a new or existing patient, who exhibits signs and/or symptoms of cognitive impairment, is required to establish or confirm a diagnosis, etiology, and severity for the condition.

Do not report cognitive assessment and care plan services if any of the required elements are not performed or are deemed unnecessary for the patient’s condition

A single physician or other qualified health care professional should not report 99483 more than once every 180 days.

CPT code 99483 provides reimbursement to physicians and other eligible billing practitioners for a comprehensive clinical visit that results in a written care plan

Eligible Provider

Any provider is eligible to report E/M services can provide this service. Eligible providers include physicians MD and DO, nurse practitioners, clinical nurse specialists, and physician assistants. 

Eligible practitioners must provide documentation that supports a moderate-to-high level of complexity in medical decision making, as defined by E/M guidelines.

The provider must also document the detailed care plan developed as a result of each required element covered by 99483

Required Elements to bill CPT 99483

CPT 99483 - Assessment of and care planning for a patient with cognitive impairment, requiring an independent historian, in the office or other outpatient, home or domiciliary or rest home, with all of the following required elements,

• Cognition-focused evaluation including a pertinent history and examination.

• Medical decision-making of moderate or high complexity.

• Functional assessment (eg, basic and instrumental activities of daily living), including decision-making capacity.

• Use of standardized instruments for the staging of dementia (eg, functional assessment staging test [FAST], clinical dementia rating [CDR]).

• Medication reconciliation and review for high-risk medications.

• Evaluation for neuropsychiatric and behavioral symptoms, including depression, including use of standardized screening instrument(s).

• Evaluation of safety (eg, home), including motor vehicle operation.

• Identification of caregiver(s), caregiver knowledge, caregiver needs, social supports, and the willingness of caregiver to take on caregiving tasks.

• Development, updating or revision, or review of an Advance Care Plan.

• Creation of a written care plan, including initial plans to address any neuropsychiatric symptoms, neurocognitive symptoms, functional limitations, and referral to community resources as needed (eg, rehabilitation services, adult day programs, support groups) shared with the patient and/or caregiver with initial education and support.

• Typically, 50 minutes are spent face-to-face with the patient and/or family or caregiver.

Many of the required assessment elements can be completed by appropriately trained members of the clinical team working with the eligible provider. 

Assessments that require the direct participation of a knowledgeable care partner or caregivers, such as a structured assessment of the patient’s functioning at home or a caregiver stress measure, may be completed prior to the clinical visit and provided to the clinician for inclusion in care planning. 

Care planning visits can be conducted in the office or other outpatient, home, domiciliary, or rest home settings.

Qualified health care professionals may report 99483 as frequently as once per 180 days

Tips

Do not report 99483 in conjunction with the following CPT codes,

• E/M services - 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99366, 99367, 99368, 99497, 99498.

• Psychiatric diagnostic procedures 90785, 90791, 90792.

• Brief emotional/behavioral assessment - 96127.

• Psychological or neuropsychological test administration 96146. 

• Health risk assessment administration 96160, 96161.

• Medication therapy management services 99605, 99606, 99607.

Click Here for Related Information

Cognitive Assessment & Care Plan - Provider's Education

The CMS to conduct provider outreach and education for the Medicare-covered Cognitive Assessment & Care Plan Services for CPT code 99483 to increase awareness of this service and its eligibility requirements.

The CMS sending education document, including a direct mailing, from the Medicare Administrative Contractors (MACs) to eligible clinicians. 

For about Medicare-covered Cognitive Assessment & Care Plan Services. The education and mailing will raise general awareness of the benefit and provide information on eligibility and billing.

Eligible Providers

• Physicians, 
• Nurse practitioners, 
• Clinical nurse specialists, 
• Certified nurse-midwives
• Physician assistants

Eligible Patients

• All beneficiaries who are cognitively impaired are eligible to receive the services under the code. 

• This includes those who have been diagnosed with Alzheimer’s, other dementias, or mild cognitive impairment. But, it also includes those individuals without a clinical diagnosis who, in the judgment of the clinician, are cognitively impaired.

Evaluation and Management services

• If a physician, or other clinicians eligible to bill Evaluation and Management services, finds a patient shows signs of cognitive impairment during a routine visit.

• Medicare covers a separate visit to more thoroughly assess the patient’s cognitive function and develops a care plan. 

• The cognitive assessment includes a detailed history and patient exam. There must be an independent historian for assessments and corresponding care plans provided under CPT code 99483.

Effective January 1, 2021, Medicare increased payment for these services, added these services to the definition of primary care services in the Medicare Shared Savings Program, and permanently allowed these services to be provided via telehealth.

Return to CCM

New Waived Tests for Labs - Modifier QW Updates

The Clinical Laboratory Improvement Amendments of 1988 (CLIA) regulations require a facility to be appropriately certified for each test performed. 

To ensure that Medicare & Medicaid only pay for laboratory tests categorized as waived complexity under CLIA in facilities with a CLIA certificate of waiver.

The listed below are the latest tests approved by the Food and Drug Administration (FDA) as waived tests under CLIA. 

The Current Procedural Terminology (CPT) codes for the following new tests must have the modifier QW to be recognized as a waived test. 

However, the below-mentioned tests did not require a QW modifier to be recognized as a waived test.

Example (i.e., CPT codes: 81002, 81025, 82270, 82272, 82962, 83026, 84830, 85013, and 85651) 

• 81002 - Dipstick or tablet reagent urinalysis – non-automated for bilirubin, glucose, hemoglobin, ketone, leukocytes, nitrite, pH, protein, specific gravity, and urobilinogen.

• 81025 - Urine pregnancy tests by visual color comparison.

• 82270 & 82272 - Fecal occult blood.

• 82962 - Blood glucose by glucose monitoring devices cleared by the FDA for home use.

• 83026 - Hemoglobin by copper sulfate – nonautomated.

• 84830 - Ovulation tests by visual color comparison for human luteinizing hormone.

• 85013 - Blood count; spun microhematocrit.

• 85651 - Erythrocyte sedimentation rate – nonautomated. 

The CPT code 80305 is required modifier QW, effective date, and description for the latest tests approved by the FDA as waived tests under CLIA is the following,

• August 25, 2020, Verify Diagnostics Inc. VeriCheck Drug Test Cup;

• August 25, 2020, Verify Diagnostics Inc. VeriCheck Drug Test Dip;

• September 23, 2020, Axium BioResearchInc.DrugExam Multi-Drug Screen Test;

• October 9, 2020, American Screening LLC Discover Panel Dip Card Tests MOR 300;

• October 9, 2020, American Screening LLC Discover Quick Cup Tests MOR 300;

• October 9, 2020, American Screening LLC Discover Quick Cup Tests MOR 2000;

• October 9, 2020, American Screening LLC Discover Plus Panel Dip Card Tests MOR 300;

• October 9, 2020, American Screening LLC Discover Plus Panel Dip Card Tests MOR 2000;

• October 9, 2020, American Screening LLC Discover Plus Quick Cup Tests MOR 300;

• October 9, 2020, American Screening LLC Discover Plus Quick Cup Tests MOR 2000;

• October 9, 2020, American Screening LLC OneScreen Plus Quick Cup Tests MOR300

• October 9, 2020, American Screening LLC OneScreen Plus Quick Cup Tests MOR2000;

• October 9, 2020, American Screening LLC Reveal Panel Dip Card Tests MOR2000;

• October 9, 2020, American Screening LLC Reveal Quick Cup Tests MOR300; and

• October 9, 2020, American Screening LLC Reveal Quick Cup Tests MOR2000.

Evaluation Management - New Patients Vs Established Patients

The E/M codes are categorized based on the service rendered in the setting and or location. 

Examples,

• Office or other outpatient setting 
• Emergency department (ED) 
• Hospital inpatient 
• Nursing facility (NF)

Patient Type 

For the billing purpose and the code selection will be depending on the service performed with the same physician either new patients or established patients. 

New Patient

An individual who did not receive any professional services from the physician and or other qualified healthcare professional or non-physician practitioner (NPP) or another physician of the same specialty and or sub specialty  who belongs to the same group practice within the previous 3 years

Established Patient

An individual who receives professional services from the physician or other qualified healthcare professional or non-physician practitioner (NPP) or another physician of the same specialty and or sub specialty who belongs to the same group practice within the previous 3 years.

Key Components 

The E/M codes are mostly selected based on three major key components to electing the appropriate level of E/M services

Major Key Components 

• History
• Examination
• Medical Decision Making (MDM)

Other Contributing Factors 

The E/M codes are rarely selected based on the Contributing Factors

• Counseling
• Coordination of care
• Nature of presenting problem
• Time.

2021 Changes

CPT code 99201 (new patient, level 1) deleted from Jan 1, 2021 and the CPT code 99211 l remain as a reportable service

The first two major key components of History and Physical Examination removed as key components for selecting the level of E&M service for office and or outpatient services (CPT 99202 to 99215).

In  before 2021, history and exam are two of the three components used to select the appropriate E&M service.

From Jan 2021, history and exam will no longer be used to select an E&M service for office and or outpatient visits, but still must be performed and documented in the medical record in order to selecting the appropriate CPT codes 99202-99215.

For 2021 E&M Changes

HRSA COVID-19 Coverage Assistance Fund and Rural Health Clinic (RHC) Payment Limits

HRSA COVID-19 Coverage Assistance Fund 

The Biden-Harris Administration is providing free access to COVID-19 vaccines for every adult living in the United States. 

Accordingly, the Health Resources and Services Administration’s (HRSA) COVID-19 Coverage Assistance Fund (CAF) will cover the costs of administering COVID-19 vaccines to patients whose health insurance doesn’t cover vaccine administration fees, or does but typically has patient cost-sharing. 

While patients cannot be billed directly for the COVID-19 vaccine fees, costs to health care providers on the front lines for administering COVID-19 vaccines to underinsured patients will now be fully covered through CAF, subject to available funding. 

As vaccination efforts accelerate, patients will increasingly gain access to COVID-19 vaccines at locations near where they live with providers they trust.

Providers are eligible for claims reimbursement if they have administered Food and Drug Administration (FDA) authorized COVID-19 vaccines under an Emergency Use Authorization (EUA) or FDA-licensed COVID-19 vaccines under a Biologics License Application (BLA) to individuals whose health plan does not cover vaccine administration fees, or does but typically has patient cost-sharing.

The eligible providers will be reimbursed at national Medicare rates for vaccine administration fees, and for any patient cost-sharing related to vaccination, including,

• Co-pays
• Deductibles,
• Co-insurance

Rural Health Clinic (RHC) Payment Limits

Effective January 1, 2021, the RHC payment limit per visit for Calendar Year (CY) 2021 is $87.52. This payment limit applies to independent RHCs and RHCs that are provider-based to a hospital with 50 or more beds.

Beginning April 1, 2021, the RHCs will begin to receive an increase in their payment limit per visit over an 8-year period, with a prescribed amount for each year from 2021, through 2028. 

Then, in subsequent years, the limit is updated by the percentage increase in MEI applicable to primary care services furnished as of the first day of that year.

The RHC payment limit per visit over an 8-year period is as follows,

• In 2021, after March 31, at $100 per visit
• In 2022, at $113 per visit
• In 2023, at $126 per visit
• In 2024, at $139 per visit
• In 2025, at $152 per visit
• In 2026, at $165 per visit
• In 2027, at $178 per visit
• In 2028, at $190 per visit

New CPT Code 99439 Replacement for CPT G2058

The chronic care management additional 20 minutes add-on CPT code G2058 was deleted from Jan 1, 2021, and the new code chronic care management CPT 99439 was introduced for the same.

G2058 - Chronic care management services, each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for the primary procedure - 99490)

99439 - Chronic care management services with the following required elements: multiple (two or more) chronic conditions; each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for the primary procedure)

• Use 99439 in conjunction with 99490 and Chronic care management services of less than 20 minutes duration, in a calendar month, are not reported separately

• Do not report 99439 more than twice per calendar month

• Do not report 99439, 99490 in the same calendar month with 90951-90970, 99339, 99340, 99374, 99375, 99377, 99378, 99379, 99380, 99487, 99489, 99491, 99605, 99606, 99607

• Do not report 99439, 99490 for service time reported with 93792, 93793, 98960, 98961, 98962, 98966, 98967, 98968, 98970, 98971, 98972, 99071, 99078, 99080, 99091, 99358, 99359, 99366, 99367, 99368, 99421, 99422, 99423, 99441, 99442, 99443, 99605, 99606, 99607

Tips

The total duration of the staff care management services must meet the time listed in the code descriptor to be reported. 

For instance, for services totaling 40 minutes, you may report 99490 (first 20 minutes) and +99439 (additional 20 minutes). 

But for 39 minutes, you should report only 99490. A total of 39 minutes does not meet the requirement of 20 minutes for 99490 and another 20 minutes for +99439.

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Evaluation and Management -Time Based Code Selection

The following codes are used to report evaluation and management services provided in the office and or outpatient setting.

The office and or outpatient setting codes CPT 99202 to 99215, the time guidelines had been changed effective from Jan 1. 2021. 

There are few changes with exiting guidelines,

The Counseling and/or coordination of care with other physicians, other qualified health care professionals has been removed and included following guidelines. 

In 2021, The time guidelines explain about that for 99202-99205 and 99212-99215, The total time spends on the encounter for the date, includes both face-to-face and non-face-to-face time spent by the provider.

Physician/other qualified health care professional time includes the following activities when performed,

• Preparing to see the patient (eg, review of tests)
• Obtaining and/or reviewing the separately obtained history
• Performing a medically appropriate examination and/or evaluation
• Counseling and educating the patient/family/caregiver
• Ordering medications, tests, or procedures
• Referring and communicating with other health care professionals (when not separately reported)
• Documenting clinical information in the electronic or other health record
• Independently interpreting results (not separately reported) and communicating results to the
• Patient/ family/caregiver
• Care coordination (not separately reported)

The appropriate CPT codes can be selected based on the time documented in the visit notes. 

Return to view MDM guidelines