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New Year-- New Billing and Coding

Look for these issues and opportunities in your 2016 billing and coding:

Advance Care Planning:

Medicare will in 2016 pay for Advance Care Planning (ACP) CPT codes established in 2015.

  • 99497– ACP 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 professional, first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.

  • +99498– each additional 30 minutes (list separately in addition to code for primary procedure).

Advance directive is described as “a document appointing an agent and/or recording the wishes of a patient pertaining to his/her medical treatment at a future time should he/she lack decisional capacity at that time.” Examples are: health care proxy, durable power of attorney for health care, living will, and DNRs.

An ACP code(s) can be reported with a standard E/M code if applicable to a single face-to-face encounter. The coding for both should be based on the encounter divided into separate and distinct services; one treating an acute or chronic disease and the other advanced care planning. It is payable with the Annual Wellness Exam as a separate procedure. Services can also be provided in separate encounters on different days.

Payment for the new ACP codes will be around $80/$71.

Ear Irrigation Services:

A new code was added when reporting services for removal of impacted cerumen without the use of instrumentation: 69209 “Removal impacted cerumen using irrigation/lavage, unilateral.” This code should not be reported on the same day as 69210 “Removal impacted cerumen requiring instrumentation, unilateral.” If service is provided on both ears, use modifier 50.

“Incident To” Services

An amendment has been made to clarify incident-to services. The clarification is that the physician who bills for the services must be the same person who directly supervised the non-physician personnel who provided the services. The direct requirement for incident-to services has not changed— the physician must be present in the office suite and available to furnish assistance and direction throughout the performance of the service. This does not mean that the billing/supervising physician also has to be the one who initiated the original care plan or service upon which the incident-to service is based; however, the services must be billed by the physician who was present and providing supervision. Medical record documentation should clearly name the supervising physician as well as the non-physician staff who performed the services.

Also reiterated was the regulation that non-physician staff are prohibited from providing incident-to services if they have been excluded from Medicare, Medicaid or any other federally funded health care programs by the OIG or had Medicare enrollment revoked.

Prolonged Services

  • Add-on codes for Prolonged Services +99354 and +99355 now apply to prolonged face-to-face outpatient psychotherapy as well as to prolonged face-to-face E/M codes. Use a primary E/M or psychotherapy code, one 99354 (30-74 minutes in addition to the time spent on the initial/primary service) per day and as many units of 99355 as needed to match the time spent. [Cannot be reported with 99415-99416]

  • 2 new add-on Prolonged Services codes have been created: +99415 and +99416 are to be used to report prolonged face-to-face clinical staff service with physician, NP or PA supervision. (List separately in addition to code for E/M). [Cannot be reported with 99354-99355]


Review your 2016 CPT Coding Book for these new available vaccine codes:

90625, 90697,90620,90621, 90630,90651

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