Bo Gamble
Administrators, managers, and even clinicians have often used the terms “coding” and “billing” interchangeably. However, these terms in fact refer to separate pieces of the health care administrative structure. Services, the actual assistance or guidance provided to the patient, are matched to a complex numerical coding system defined in the American Medical Association (AMA) Current Procedural Terminology guide[1]. This guide allows physicians to report how their time was spent and what services were rendered to patients. Medical billing codes, which tell insurers what services they are reimbursing, have not always aligned with the service coding system.
Prior to 2013, the principal codes used in health care dated back to 1995 and included three components: history, physical examination, and medical decision. These components had five different levels ranging from low to high complexity. Almost all office visits, regardless of content and purpose, were required to conform to one of the five appropriate levels. Electronic medical record (EMR) templates, physician notes, patient scheduling, and staffing reflected these same guidelines. Compliance to the coding guidelines forced physicians to write long and sometimes cumbersome notes, and the main purpose of the visit was oftentimes overlooked.
In 2013, things began to change for the better. Service codes were being introduced that were more specific for important conversations and were evidence of higher quality care. Some examples and an evolution:
2013 – Transitional Care Management: 99495 & 99496 …services are for a new or established patient whose medical and/or psychosocial problems require moderate or high complexity medical decision-making during transitions in care from an inpatient hospital setting… These codes assured payers that patient care was managed effectively when they left the hospital. This includes follow-up instructions, communications, navigation, etc. within seven or 14 days from hospital discharge.
2015 – Chronic Care Management: 99490 & 99491 …Patients who receive chronic care management services have two or more chronic continuous or episodic health conditions that are expected to last at least 12 months… The majority of cancer patients likely fit this category.
2018 – Advanced Care Planning: 99497 & 99498 …face-to-face service between a physician or other qualified health care professional and a patient, family member, or surrogate in counseling and discussing advance directives, with or without completing relevant legal forms. These service codes are very important to cancer care, and measures in this area have become standard in most regional and national reform models for cancer care. Patient discussions in this area have been instrumental in aligning care with patient wishes near end of life.
January 2021 brought the biggest changes to services, and coding and billing. History and/or Physical Exam are no longer required for new or established patients.[2] The focus is only on medical decision-making – the most important aspect of effective treatment. Although some of the guidelines are more complicated, the door has been opened for efficiency in visit notes, communications to other care teams, charting templates, patient scheduling, and staffing. (For example, many pages of a chart note could be eliminated if only meaningful information was included, and tables of repeated history and normals from the physical exam were not included.) Adjusting procedures and workflows to accommodate these improvements will benefit patients and those that are responsible for delivering high quality cancer care.
It will not be easy to change more than 25 years of developed flows and processes. This paradigm shift will require team leadership, guidance from your certified professional coder, and support from your compliance team. This collaborative effort will bear fruit for the known changes and solidify the foundation for adapting future changes. The APP’s concern and care for the cancer patient will be critical to the adaption of these changes and the cancer care of the future.
[1] AMA Current Procedural Terminology 2021
[2] https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management
Bo Gamble
Director of Strategic Practice Initiatives – Community Oncology Alliance (COA)
