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Coding Corner: The Work Between Visits: Principle Care Management | Rosa Miller Polan, MD and David Holtz, MD

Coding ToolsCoding
Feb 2, 2022

David Holtz, MD

Rosa Miller Polan, MD

Taking care of complex patients requires a lot of work in between visits, both on the part of the provider and by the clinical staff. Coding changes by the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) effective Jan. 1, 2022, attempt to recognize that work.

Use these codes for the treatment of outpatients under the following circumstances:

  • One complex chronic condition
  • Condition severe enough that patient is at risk for hospitalization or was recently hospitalized
  • Condition requires development or revision of care plan
  • Condition requires frequent medication adjustments and/or condition is unusually complex due to comorbidities.

Principle Care Management Codes:

  • 99424 (formerly G2064) – physician or APP work, first 30 mins, per calendar month
  • 99425 – physician or APP work, each additional 30 mins, per calendar month
  • 99426 (formerly G2065) – clinical staff work, first 30 mins, per calendar month
  • 99427 – clinical staff work, each additional 30 mins, per calendar month

Brad Hart, President of Reproductive Medicine Administrative Consulting, Inc., and long-time coding consultant for the SGO had the following comments: “These codes are intended to compensate providers for all for the management work that they do in complex cases that occurs outside the context of traditional E/M visits.”

Significant challenges (if Medicare and other private payers reimburse for them) are:

  • Constructing a system by which to document the services performed and to keep track of the cumulative time spent on this activity each month.
  • Defining who is responsible for calculating and submitting a charge for this service at the end of the month.
  • Remembering that this time-based code is different than previous time-based codes. In the past, you could bill a “30 minute” code if you provided at least 16 minutes of service — more than 50% of the required time. These codes require the full amount of time (30 minutes) to be provided to bill it at all.
  • Remembering that if you are going to bill the staff time codes (99426 and 99427), you are limited to a maximum of 90 minutes of time (99426 x 1 and 99427 x 2).

The SGO Coding and Reimbursement Subcommittee invites you to join us for the 2022 Coding Course during the SGO 2022 Annual Meeting on Women’s Cancer. This year’s course will be a hybrid of prerecorded sessions and a live Q&A session to be held on Friday March 18, 2022, in Phoenix, AZ. Topics will include Complex Surgical Coding, Modifiers Demystified, Office E&M Coding and Telemedicine.

The prerecorded sessions will be available for viewing prior to the start of the hybrid SGO 2022 Annual Meeting. We hope you will view them and bring your questions virtually or in person to the live Q&A session!

David Holtz, MD, is a gynecologic oncologist at Lankenau Hospital in Wynnewood, PA.
Rosa Miller Polan, MD, is a gynecologic oncology fellow at Wayne State University/Barbara Ann Karmanos Cancer Center and the 2022-2024 SGO Coding Fellow.

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