View Only

Policy Perspectives, August 2017

By User Admin posted 07-31-2017 11:00 PM



Submitted by Stephanie Farnia, ASBMT Director of Health Policy and Strategic Relations

I am turning the column over this month to a guest co-author – Dr. James Gajewski – who is a long-time ASBMT volunteer in relation to reimbursement issues and currently serving as the Practice Policy Consultant to the Society.  The focus of this month’s column is on a series of relatively new codes for use in billing time spent in clinic with patients.  In addition, we were hoping to have an update on the new CMS physician specialty code and how to implement the status change within your systems, but CMS has not yet issued the final codes and specifications needed.  Please look for this information in the September edition of ASBMT eNews. 


Care Management Visits and Appropriate Billing

In the past decade, several internal medicine specialty societies (including ASBMT) have recognized that is becoming increasingly difficult for non-surgical physicians to fully fund their salary on patient care visits and services.  For ASBMT members, a significant part of this issue is that the time and discussion it takes to deal with the complex needs of HCT patients extends far beyond the economic valuation of the Evaluation and Management (E/M) codes.  Historically, time spent in care coordination outside of a patients’ clinic visit – for coordination of treatment related to post-transplant complications, as an example - was not payable by Medicare.   As commercial insurance often mirrors Medicare billing guidance, non-governmental payers also did not frequently reimburse these efforts. 

The efforts of the specialty society collaboration led by the American College of Physicians (ACP) included the following changes in the past decade:

  1. Increase in the Relative Value Unit (RVU) value of all Evaluation & Management codes (2006). While the RVU Update Committee (RUC) initially approved increases of 15% to 30% (depending on the code), this was lowered to 5-15% by CMS during the annual Physician Fee Schedule rule-making process.
  2. Development of new codes recognizing that care management and care coordination is a significant amount of work performed by physicians between outpatient visits and/or inpatient stays (2016). Six new codes have been written, valued by the RUC and recognized by CMS for payment.
  3. Development of new codes for discussions with patient and family members for advanced directives (2015).  Two new codes for advance care planning were approved, valued and recognized by CMS to account for this particular type of patient/family interaction.

All of the new codes (found at the end of this article) can be billed by both physicians and licensed Advanced Practice Professionals (APPs), provided one is licensed to bill independently.   In addition to making sure that your total RVU assessments are reflective of your work effort, these codes have an additional payment associated with them – known as a practice expense payment - to help cover cost of nurse coordinators and data managers.  This is particularly helpful in the context of transplant programs and the need for data managers to support CIBMTR reporting efforts.


Code Spotlight: Care Management Codes

CPT codes 99358 and 99359 represent Prolonged Service, Non-Face-to-Face time, which should be billed after providing prolonged service that is not in front of patient or after extended floor time during an inpatient stay.  The use of these codes must be related both to a prior or future E/M service and to ongoing care.   The time captured by these codes does not need to be on a day an E/M service was provided.  99358 will cover the first hour of prolonged service and can be billed after at least 31 minutes of time has been spent. The add-on code 99359 can be used once more than 76 minutes of service time has been utilized.  Examples of things this service can cover is review of voluminous outside records for initial or follow-up visit, arrangement of home care, conversations with patient or caregiver with homebound patient, conversations with payers for authorization when physician time is required by payer, and/or arrangement and review of home care orders, such as home TPN management.  Prolonged time on floor (beyond 65 minutes) on a follow-up day can be billed as Prolonged Service, Face-to-Face Time using CPT codes 99356 and 99357, but prolonged time in clinic but not in front of patient must be billed as Prolonged Service, Non-Face-to-Face. 

Advance Care Planning: CPT 99497 and 99498 should be billed for interactions focused on advance care planning prior to HCT or end-of-life discussions with the patient or family members. If these discussions take 16 to 45 minutes, 99497 can be used.  

Transitional Care: CPT codes 99495 and 99496 can be used for the first outpatient visit after an inpatient admission. This will cover care coordination for the first month after hospital discharge.  Note: this code requires medication reconciliation which is best documented by pill bottle review with patient by physician, advanced practice professional provider or nurse; it is not adequate to check medication review on an electronic health care record without sufficient documentation. 

Complex Chronic Care Management: CPT 99487 can be billed for care coordination time spent developing a month-long initial chemotherapy or infusion plan, provided a copy of the care plan was given to the patient.  Prolonged service, non-face-to-face codes cannot be billed during time periods covered by chronic or complex chronic care management or transitional care codes.       

Future Efforts to Improve Coding

ASBMT recognizes that the current E/M coding documentation requirements, particularly in era of electronic health care records, are time consuming and often do not help patient care delivery.  ASBMT is working with ACP, the American Medical Association and congressional supporters to ask that CMS revise the E/M documentation guidelines to reduce this burden.  Knowing that much of HCT care is delivered by an advanced practice professional and an attending physician working together, ASBMT has asked that “split/shared” visits – those patient encounters resulting in 2 separate notes by the APP and attending – be reconsidered for updated billing guidance.    

  • 99354 prolonged service face-to-face when an outpatient visit requires prolonged time in front of patient: 2.33 RVUs
  • 99355 prolonged service face-to-face outpatient add-on, 30-minute increment: 1.77 RVUs
  • 99356   prolonged service face-to-face when an inpatient visit requires prolonged: 1.71 RVUs
  • 99357 prolonged service inpatient visit add-on 30-minute increment: 1.71 RVUs
  • 99358 prolonged service non-face-to-face: 2.1 RVUs
  • 99359 prolonged service non-,ace-to-,ace add-on, 30-minute increment: 1 RVUs
  • 99487 complex chronic care management-management of two or more diseases with either initiation of a new care plan or revision of a care plan requiring supervision of 60 minutes of staff time (staff cannot be APP)]: 1 RVU
  • 99489 complex chronic care management-management of two or more diseases with initiation of a new care plan or revision of a prior care plan requiring more than 60 minutes of staff time supervision for every 30-minute increment: 0.5 RVU 
  • 99490 chronic care management-management of two or more disease with initiation of a new care plan or revision of a prior care plan requiring more than 20 minutes of staff time: -0.61 RVU
  • 99495 transitional care – first outpatient visit after inpatient admission: 2.11 RVU
  • 99496 complex first outpatient visit after inpatient admission-when complexity of care requires an office visit within seven days of discharge: 3.05 RVU
  • 99497 advanced care planning-for discussion of advanced directive, end-of-life discussions and planning with patient and family members. First 30 minutes: 1.5 RVU
  • 99498 advance care planning for every 30 minutes beyond initial 30 minutes: 1.4 RVU


The information provided in this article represents our best efforts to provide accurate information and useful advice; however, the ASBMT cannot guarantee that third-party payers will recognize and accept the coding and documentation recommendations. As CPT®, ICD-10-CM and HCPCS codes change annually, you should reference the current CPT®, ICD-10-CM and HCPCS manuals and follow the "Documentation Guidelines for Evaluation and Management Services" for the most detailed and up-to-date information. This information is taken from publicly available sources. The ASMBT cannot guarantee reimbursement for services as an outcome of the information and/or data used and disclaims any responsibility for denial of reimbursement. This information is intended for informational purposes only. Current Procedural Terminology (CPT©) is copyright and trademark of the 2016 American Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT©. The AMA assumes no liability for the data contained herein.

To see more helpful coding information, click here.



Read the entire August 2017 ASBMT eNews here.