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Psychiatry Coding & Reimbursement Alert

CCI 22.0 Update:

Glimpse into CCI 22.0 Edits When Reporting Certain E/M Services

Make the distinction between modifier indicators of ‘1’ and ‘0.’

If you scour through the latest coding edits affecting psychiatry coding in 2016, you will notice that these edits cover the new prolonged clinical staff service codes and advance care planning codes.

Here’s what you need to know about the latest version 22.0 of the Correct Coding Initiative (CCI) edits, which added 57,161 new bundles and deleted 20,842 more effective on Jan. 1, 2016, and how it will affect your coding.

Consider CCI When Reporting Prolonged Clinical Staff Services

CPT® 2016 saw the introduction of the following prolonged services codes to help you capture work your clinical staff performs after your clinician sees the patient for an E/M service:

  • +99415 - Prolonged clinical staff service [the service beyond the typical service time] during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour [List separately in addition to code for outpatient Evaluation and Management service]
  • +99416 - Prolonged clinical staff service [the service beyond the typical service time] during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; each additional 30 minutes [List separately in addition to code for prolonged service].

You report the add-on code +99415 for the first hour of prolonged time that your clinical staff spends with the patient and report +99416 for each additional 30 minutes spent beyond the first hour.

According to CCI 22.0, these codes are bundled with the following psychiatry codes that you will use in your everyday psychiatry practice:

  • Psychiatric diagnostic evaluation codes (90791-90792)
  • Individual psychotherapy codes (90832-90838)
  • Psychoanalysis code (90845)
  • Narcosynthesis for psychiatric diagnostic and therapeutic purposes code (90865)
  • Hypnotherapy code (90880)

Modifier indicator: The modifier indicator to the edit bundle between prolonged clinical staff service codes, +99415 and +99416 and the above mentioned codes is ‘0,’ which means you cannot overcome the edit bundle using any modifier. So, you cannot report clinical staff services separately using these add-on codes with the above mentioned psychiatry related codes.

According to CCI 22.0, these prolonged clinical staff services codes are also bundled into a few psychiatry related codes with the modifier indicator ‘1,’ which means you can use a modifier in certain circumstances to overcome the edit bundle and report these services separately. The psychiatry codes with which these prolonged clinical staff services codes are bundled with the modifier indicator ‘1’ include:

  • Family psychotherapy codes (90846-90847)
  • Multiple-family group psychotherapy code (90849)
  • Group psychotherapy code (90853)
  • Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment code (90869)
  • Group psychotherapy codes in a partial hospitalization setting (HCPCS codes, G0410 and G0411)

As the prolonged clinical staff services codes are column 2 codes in the above mentioned code bundles, you will need to append a modifier to these codes. The modifier that you will use in these circumstances is 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service).

Note: You should also consider these prolonged services codes (99415, 99416) included in prolonged care services codes, 99354 (Prolonged evaluation and management or psychotherapy service[s][beyond the typical service time of the primary procedure] in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour [List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service]) and +99355 (…each additional 30 minutes [List separately in addition to code for prolonged service]). “These edits are consistent with CPT® guidelines preceding codes 99415 and 99416. Those guidelines clearly state that you should not report 99415 or 99416 with 99354 or 99355,” observes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Watch These Edits with Advance Care Planning E/M Codes

When your clinician discusses and shares advance care planning for up to 30 minutes with a patient, his family, or an individual representing the patient, regarding the future healthcare needs of the patient, you report this service with an E/M code. The code that you report for this service is 99497 (Advance care planning including the explanation and discussion of advance directives such as standard forms [with completion of such forms, when performed], by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member[s], and/or surrogate).

According to CCI 22.0, you will face edits if you are trying to report 99497 with any of these following psychiatry related codes:

  • Psychiatric diagnostic evaluation codes (90791-90792)
  • Individual psychotherapy codes (90832, 90834 and 90837)
  • Psychoanalysis code (90845)
  • Narcosynthesis for psychiatric diagnostic and therapeutic purposes code (90865)
  • Hypnotherapy code (90880)

Modifier indicator: The modifier indicator to the edit bundle between 99497 and the above mentioned codes is ‘0,’ which means you cannot overcome the edit bundle using any modifier. So, you cannot report 99497 separately with the above mentioned psychiatry related codes.

“Code 99497 is not new, but 2016 is the first year that Medicare is covering and paying for it, which explains the addition of the edits involving 99497 in CCI 22.0,” Moore notes.

Again, according to CCI 22.0, 99497 is bundled into a few psychiatry related codes with the modifier indicator ‘1.’ So, these edits can be undone using a suitable modifier to allow you to break the edit bundle and report these services separately. The psychiatry codes with which 99497 are bundled with the modifier indicator ‘1’ include:

  • Family psychotherapy codes (90846-90847)
  • Multiple-family group psychotherapy code (90849)
  • Group psychotherapy code (90853)
  • Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment codes (90867-90869)
  • Developmental testing code (96111)

As 99497 is the column 2 code in the above mentioned code bundles, you will need to append a modifier to the advance care planning code to enable you to report both the codes separately. The modifier that you will use in such circumstances is 25.

According to CCI 22.0, the advance care planning code 99497 is listed as a column 1 code with the following codes:

  • Pharmacological management code (90863) - 0
  • Psychological testing codes (96101-96103) - 1
  • Aphasia assessment code (96105) - 1
  • Neurobehavioral status exam code (96116) - 1
  • Neuropsychological testing codes (96118-96120) - 1
  • Standardized cognitive performance testing code (96125) - 1
  • Health and behavioral assessment codes (96150-96151) - 0
  • Health and behavioral intervention codes (96152-96155) - 0

The modifier indicator in the edit bundles between 99497 and the pharmacological management code (90863), health and behavioral assessment codes, or health and behavioral intervention codes is ‘0,’ which means you cannot overcome this edit bundle under any circumstances. The rest of the above mentioned code bundles carry the modifier indicator ‘1,’ which means you can break the code bundling using a suitable modifier. You will have to use an appropriate modifier appended to the code other than 99497 in each case.