What’s in Store for Internal Medicine Coding in 2016?

Internal medicine changes for 2016 are around the corner. Prolonged care codes are being revised and prolonged clinical staff services codes are being included. There are also changes proposed to incident to billing regarding change in supervision.

New Prolonged Staff Services codes in 2016

Prolonged service codes are add-on codes used when physicians or other healthcare professionals provide prolonged service involving direct contact with patients, beyond the usual service. Two new CPT® codes for 2016 can be used to report Clinical Staff Services. These are codes ending with 99359.

Proposed Rule for Incident to Billing

With the release of the proposed Medicare Physician Fee Schedule Rule for CY2016, CMS proposed that the language from the “incident to” regulation, which can be interpreted as allowing the physician/practitioner supervising the auxiliary personnel to not be the same physician/practitioner upon whose professional service the incident to service is based, is removed. In other words, the billing physician/practitioner for “incident to” services must also be the supervising physician or practitioner. CMS’ intent is to ensure that billing physicians/ practitioners have a personal role and responsibility in billing and receiving payment for services incident to their professional services.

Incident-to services must be part of the normal course of treatment for a patient. The physician performs an initial service and remains involved in the treatment later as well. Some essential requirements for “incident to” services are:

  • They need to be an essential part of the treatment course.
  • They should usually be without charge i.e. included in physician bills.
  • Need to be offered by physician clinics rather than in institutions.
  • They need to be an expense to the physician or clinic.
  • Lastly, they need to be supervised by a physician or practitioner.

However, the proposed rule does not clarify whether CMS would consider practitioners in the same group or clinic to be considered the same practitioner when applying the new “incident to” requirements. If CMS decided to apply the direct supervision requirements to groups of physicians, it could seriously affect practices such as oncology where patients often undergo a series of treatments and supervising and treating physicians may be different. The proposed rule may also find itself contradicting Stark Law, according to which group practice productivity credit for incident-to services accrues to the physician upon whose services the incident-to service is based, rather than the supervising physician/billing.

There are other changes expected and proposed, that might affect the practices such as changes to Modifier 59 and the use of one of 4 subset modifiers. Changes to radiology codes may also affect your practice. For more on expected and proposed changes to Internal Medicine coding in 2016 and how they may affect you, check out this audioconference by expert speaker Jill M. Young, CPC, CEDC, CIMC.

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