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Coding Corner: CPT® 2017: Medicare coding and coverage updates



March 01, 2017
Area(s) of Interest: Payor Issues and Reimbursement Practice Management 

CPR’s “Coding Corner” focuses on coding, compliance and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care.  


Medicare payers often stipulate unique codes and coverage requirements not found within the CPT® codebook. For example, in 2017 the Centers for Medicare & Medicaid Services (CMS) continues to require the use of dedicated “G” codes (in place of CPT® codes) to describe mammography. But, in a reversal of previous policy, CMS now will allow separate reporting of certain prolonged services that do not include time spent face-to-face with the patient. 


Stick with “G” codes for mammography
The 2017 CPT® codebook introduced three new codes to describe mammography services. Unlike the codes they replaced (77051, 77052, 77055, 77056 and 77057), the new codes specifically include computer-assisted detection (CAD), when performed:



  • 77065 Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral

  • 77066 Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral

  • 77067 Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed


Additionally, the new code descriptors exactly match those of HCPCS codes G0206, G0204 and G0202, respectively, which were required when reporting mammography to Medicare payors. The expected result is that Medicare would adopt 77065-77067 in place of the “G” codes for 2017. But, due to technical issues, CMS was unable to ready its systems to process claims using CPT codes 77065, 77066 and 77067. Although CMS intends to recognize the CPT® codes in 2018, mammography claims to Medicare in 2017 must continue to use G0206, G0204 and G0202.


Specifically, CMS instructs:


Mammography is described using the following codes:



  • G0202 Screening mammography, bilateral (2-view study of each breast), including computer- aided detection (CAD) when performed.

  • G0204 Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral.

  • G0206 Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral.


Breast tomosynthesis is described using the following add-on codes:



  • 77063 Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure)

  • G0279 Diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to G0204 or G0206).


When breast tomosynthesis is furnished, practitioners should report one of G0202, G0204, or G0206 and one of G0279 or 77063. For purposes of billing digital breast tomosynthesis, the appropriate, accompanying 2D image(s) may either be acquired or synthesized.


Source: Frequently Asked Questions for Mammography Services


CMS now covers 99358, +99359 prolonged services
CMS typically does not allow separate payment for physician services that do not require face-to-face time with a patient. As of January 1, 2017, however, CMS has made an exception and will now allow Medicare coverage for non face-to-face prolonged service codes 99358 Prolonged evaluation and management service before and/or after direct patient care; first hour and +99359 …each additional 30 minutes (List separately in addition to code for prolonged service), in compliance with CPT® guidelines.


Source: CMS Transmittal 3678, Change Request 9905 (Dec. 16, 2016)


CPT® Evaluation and Management/Prolonged Services instructions dictate:


Codes 99358 and 99359 are used when a prolonged service is provided that is neither face-to-face time in the office or outpatient setting, nor additional unit/floor time in the hospital or nursing facility setting during the same session of an evaluation and management service and is beyond the usual physician or other qualified health care professional service time.


Codes 99358 and 99359 are to be reported in addition to other evaluation and management service codes, to which they relate. “For example,” the CPT® codebook explains, “extensive record review may relate to a previous evaluation and management service performed earlier and commences upon receipt of past records.”


In keeping with CPT® requirements, CMS stresses that “codes 99358 and 99359 cannot be reported during the same service period as complex chronic care management (CCM) services or transitional care management services. They are not reported for time spent in non-face-to-face care described by more specific codes having no upper time limit in the CPT code set.” CMS further stipulates, “99358 and 99359 can only be used to report extended qualifying time of the billing physician or other practitioner (not clinical staff).”


Codes 99358 and 99359 are time-based and include “the total duration of non-face-to-face time spent by a physician or other qualified health care profession on a given date providing prolonged services, even if the time…is not continuous,” according to CPT®. The codes are applied as follows:


























Total duration of services



Coding


< 30 minutesNot reported separately
30-74 minutes99358
75-104 minutes99358, 99359
105-134 minutes99358, 99359 x 2

Documentation should summarize the necessity and specific content of the prolonged services. See the CPT® codebook for additional guidelines to report prolonged services. 

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