Betsy Nicoletti, MS

The Coding Expert Answers Your Questions

Editor’s Note: Betsy Nicoletti, MS, a nationally recognized coding expert, will take your coding questions via email and provide guidance on how to code properly to maximize reimbursement. Have a question about coding? Send it here.

In this column, Nicoletti answers some questions received in the past few months on a variety of topics of interest to physicians.

Telemedicine Coding for Medicare Patients

Question: Our office is interested in telemedicine. What are the rules and Medicare reimbursement for coding both a telemedicine visit and a medication management telemedicine visit?

Answer: Medicare only pays for telemedicine services if the patient is in a “medically underserved area” (MUA). These are defined as areas or populations designated by the US Health Resources & Services Administration as having too few primary care providers, high infant mortality, high poverty, or a high elderly population.^[1] If you think your practice area might fall under that definition, you can check it online here.

The patient’s facility bills and is paid a small fee as the “originating site,” and the distant physician/nurse practitioner or physician assistant bills for the service provided. You can read the transmittal here and use this tool to see if your patients are in an MUA.

Billing for Pharmacist Services

Question: I am a pharmacist practicing in an academic teaching hospital. Can you explain how internal medicine pharmacists in the acute care setting bill for services?

Question: If a physician has a collaborative agreement in place with a pharmacist, can a pharmacist perform parts of the Annual Wellness Visit, the physician complete the rest of it, and the physician then bills for it?

Answers: Although they provide valuable services to the care team, pharmacists currently are not a recognized specialty and may not enroll with Medicare to perform and bill for services. The scope of practice of pharmacists does not include providing evaluation and management (E/M) services, such as office visits or hospital visits.

The answer to the first question is that a pharmacist could not perform a service and bill Medicare Part B for consultative care in an inpatient stay. The hospital that employs the pharmacist includes that cost on its Medicare cost report.

Regarding the second question, any employed staff member in a physician practice could perform the health risk assessment and screenings required for a Medicare wellness visit or Annual Wellness Visit. This service is usually performed by a medical assistant or other clinical nursing staff. A pharmacist could not independently perform the wellness visit, as this is out of their scope of practice.

Post-discharge Medication Reconciliation

Question: I am a pediatrician at a rural family medical center. Are there any codes for medication reconciliation after hospital or ER discharge?

Answer: Medication reconciliation is a required component of transitional care management, which may be billed when a patient is discharged from an inpatient, observation, partial hospitalization, or nursing facility to a non-facility setting (home, rest home, domiciliary care, or independent living). TCM codes 99495 and 99496 have many specific, additional requirements.

TCM services are used for patients with medical and/or psychosocial complexity requiring moderate- or high-complexity medical decision-making (MDM). The practice must call the patient within 2 business days, perform an E/M service within 7 days for patients with high-complexity MDM, and within 14 days for patients with moderate-complexity MDM.

Additionally, Current Procedural Terminology (CPT) states, “TCM is comprised of one face-to-face visit within the specified timeframes, in combination with non-face-to-face services that may be performed by the physician or other qualified health care professional and/or licensed clinical staff under his/her direction.”^[2]

CPT code 1111F (Discharge medications reconciled with the current medication list in outpatient medical record) may be reported, but it is a Category II CPT code, which is a supplemental tracking code that can be used for performance measurement. However, 1111F does not have any relative value units or payment associated with it.

Correct Coding for Advanced Care Planning

Question: What is the best way to bill for goals of care/end-of-life planning discussions? As an oncologist, these conversations take a significant amount of my time.

Answer: For these discussions, use Advance Care Planning codes 99497 and 99498.

Code 99497 for advance care planning includes the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed) by the physician or other qualified healthcare professional—the first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.

Use code 99498 for each additional 30 minutes spent with the patient.

These codes may be performed on the same day as an E/M service, except critical care, or on a day when no other service is provided. These are time-based codes, and the time spent in the discussion must be documented in the medical record. The discussion may be with the patient, family member, and/or surrogate.

The codes follow the CPT rule for time: “A unit of time is attained when the mid-point is passed. For example, an hour is attained when 31 minutes have elapsed (more than midway between zero and sixty minutes).”^[3]

That is, bill 99497 when the service takes over 15 minutes, and add on 99498 if the service takes over 45 minutes. Do not double-count the time spent in performing any other services with the time in advance care planning.

Have a coding question? Send it in and it may be answered in a future column. (Please be sure to note your specialty in the text of the question.)