Medical Home Crosswalk to Reimbursement for Services

NCQA’s Patient-Centered Medical Home (PCMH) 2011

Nationwide, 13% of all children have special health care needs. Obtaining adequate reimbursement for the additional services associated with providing a medical home to these children is essential.  This reimbursement tool identifies the range of relevant codes that could be used to finance components of a medical home.  These components, as defined by the National Institute for Children’s Healthcare Quality and the Center for Medical Home Improvement, include community, health system, partnership support, delivery system design, decision support, and clinical information system. This tool also contains an index of medical home codes and selected vignettes.

According to the American Academy of Pediatrics (AAP), in order to increase your efficiency, code correctly; follow CPT guidelines; use the most specific ICD code possible; use modifiers when appropriate; know your carriers; know your contracted fee schedule; check every explanation of benefits; develop a relationship with one person at every carrier; file appeals (and keep on top of them!); and document your services. The Golden Rule is: if you don’t document it, you didn’t do it! For additional coding information, please refer to the AAP’s Coding for Pediatrics, 2003.

It is critically important to work with insurance carriers, Medicaid and SCHIP officials, and managed care executives on a proactive basis to avoid the added financial risk that comes with caring for children with special health care needs. For example, physicians should inform carriers about new CPT codes, such as health and behavior assessment and intervention. They should also meet with carriers to review whether the CPT codes listed in this reimbursement tool are covered and whether carriers have a pre-determined list of ICD-9 codes that primary care providers can bill for.  For example, often carriers will not reimburse primary care physicians for psychiatric diagnostic codes. Finally, contact your AAP state chapter, many of whom have started Pediatric Councils to become involved in advocacy work to correct reimbursement problems that pediatricians and family physicians are having in their local communities.

The federal Maternal and Child Health Bureau has as one of its six national goals for 2010 the need to assure that all children with special health care needs have access to a medical home. Elements of a medical home include having continuity of care, an established doctor-patient relationship, easy access to specialty care when needed, coordinated care, and family-centered care.  Aligning reimbursement policies to support these medical home functions will be critical in assuring progress in meeting this national health goal.
November 2003. All rights reserved. Individuals and organizations may replicate and use these materials without charge.  Any such reproduction should include an acknowledgment as follows:

Developed by Margaret McManus, Alan Kohrt, Joel Bradley, and Linda Walsh in collaboration with the Center for Medical Home Improvement, the American Academy of Pediatrics, and the National Institute for Children’s Healthcare Quality.  Funded by the Maternal and Child Health Bureau, U.S. Department of Health and Human Services through the Maternal and Child Health Policy Research Center.

Assessment, goal setting, and care planning

Ø  Initial or periodic comprehensive preventive medicine services (99381-99385, 99391-99395)

Ø  Office or other outpatient visit for evaluation and management (99201-99205, 99211-99215)

Ø  Prolonged physician services with or without direct patient contact (99354-99359)

Ø  Health and behavior assessment (96150, 96151)

Ø  Office or other outpatient consultation services (99241-99245, 99251-99255)

Ø  Team conferences (99361, 99362)

Ø  Care plan oversight services (99374-99380)

Ø  Hospital discharge day management (99238,99239 Health and behavior assessment (96150, 96151)

Ø  Health risk assessment instrument (99420)

Ø  Screening test of visual acuity (99173)

Ø  Audiologic screening test, pure tone, air only (92551-92553)

Ø  Evaluation of speech, language, voice, communication, auditory processing, and/or aural rehabilitation status (92506)

Ø  Central nervous system assessments and tests (96100, 96105, 96110, 96111, 96115, 96117)

Ø  Special reports (99080)

Ø  Disability evaluation services (99450)

Education

Ø  Initial or periodic comprehensive preventive medicine services (99381-99385, 99391-99395)

Ø  Preventive medicine, individual and group counseling (99401-99404, 99411-99412)

Ø  Health and behavior intervention, individual and group, with or without patient present (96152-96155)

Ø  Medical nutrition therapy (97802-97804)

Ø  Physician educational services (99078)

Ø  Educational supplies (99071)

Communications

Ø  Telephone calls (99371-99373)

Ø  Team conferences (99361, 99362)

Ø  Care plan oversight services (99374, 99380)

Ø  Prolonged physician services with or without direct patient contact (99354-99359)

Medical home team encounters

Ø  Office or other outpatient services for evaluation and management (99201-99205, 99211-99215)

Ø  Modifiers (-25)

Ø  Prolonged physician services with or without direct patient contact (99354-99359)

Ø  Telephone calls (99371-99373)

Ø  Services requested after hours (99050); services requested between 10 pm and 8 am (99052); services requested on Sundays and holidays (99054); services provided at request of patient at location other than physician’s office (99056); office services requested on an emergency basis (99058)

Ø  Home visits (99341-99345, 99347-99350)

Ø  Special reports (99080)

Ø  Analysis of clinical data (99090)

Ø  Collection and interpretation of physiologic data (99091)

Preventive services

Ø  Initial or periodic comprehensive preventive medicine services (99381-99385, 99391-99395)

Ø  Preventive medicine, individual and group counseling (99401-99404, 99411-99412)

Ø  Health risk assessment instrument (99420)

Ø  Health and behavior assessment (96150, 96151)

Ø  Health and behavior intervention, individual and group, with or without patient present  (96152-96155)

Ø  Screening test of visual acuity (99173)

Ø  Audiologic screening test, pure tone, air only (92551-92553)

Ø  Evaluation of speech, language, voice, communication, auditory processing, and/or aural rehabilitation status (92506)

Ø  Central nervous system assessments and tests (neurocognitive, mental status, speech testing) (96100, 96105,96110, 96111, 96115, 96117)

Ø  Medical nutrition therapy (97802-97804)

Ø  Physician educational services in group setting (99078)

Ø  Educational supplies (99071)

Care coordination

Ø  Prolonged physician services (99354-99359)

Ø  Office or other outpatient services for evaluation and management (99201-99205, 99211-99215)

Ø  Care plan oversight services (99374-99380)

Ø  Team conferences (99361, 99362)

Ø  Telephone calls (99371-99373)

Ø  Health and behavior intervention, individual and group, with or without patient present (96152-96155)

Ø  Hospital discharge day management (99238, 99239)

Ø  Special reports (99080)

Pediatric medical and surgical subspecialists Ø  Office or other outpatient consultations (99241-99245)

Ø  Office or other inpatient consultations (99251-99255, 99261-99263)

Ø  Confirmatory consultations (99271-99275)

Ø  Office or other outpatient services for evaluation and management (99201-99205, 99211-99215)

Mental health services

Ø  Psychiatric diagnostic or evaluative interview (90801, 90802)

Ø  Health and behavior assessment (96150, 96151)

Ø  Health and behavior intervention (96152-96155)

Ø  Individual psychotherapy (90804-90815)

Ø  Family or group psychotherapy (90846, 90847, 90849, 90857)

Ø  Pharmacologic management (90862)

Ø  Central nervous assessments and tests (neurocognitive, mental status, speech testing) (96100, 96105, 96110, 96111, 96115, 96117)

Ø  Psychiatric evaluation and preparation of records (90885, 90887)

Ø  Preparation of reports (90889)

See care coordination, communication, & education services listed under delivery system design

Special Services

Ø  Analysis of clinical data (99090)

Ø  Collection and interpretation of physiologic data (99091)

Ø  Special reports (99080)

99205              Same, new patient, high severity problem, 60 min.

99211        Office or other outpatient visit, established patient, self limited or minor problem, 10 min.

99212              Same, established patient, low to moderate severity problem, 20 min.

99213              Same, established patient, moderate severity problem, 45 min.

99214              Same, established patient, moderate to high severity problem, 60 min.

99215              Same, established patient, high severity problem, 60 min.

99238        Hospital discharge day management, 30 min.

99239              Same, more than 30 min.

99241        Office or other outpatient consultation, new or established patient, self-limited or minor problem, 15 min.

99242              Same, low severity problem, 30 min.

99243              Same, moderate severity problem, 45 min.

99244              Same, moderate to high severity problem, 60 min.

99245              Same, moderate to high severity problem, 80 min.

99251        Initial inpatient consultation, new or established patient, self-limited or minor problem, 20 min.

99252              Same, low severity problem, 40 min.

99253              Same, moderate severity problem, 55 min.

99254              Same, moderate to high severity problem, 80 min.

99255              Same, moderate to high severity problem, 110 min.

99261        Follow-up inpatient consultations; established patient, stable or recovering or improving, 10 min.

99262              Same, inadequate response to therapy or minor complication, 20 min.

99263              Same, unstable or significant complication or significant new problem, 30 min.

99271        Confirmatory consultations, new or established, self-limited or minor problem

99272              Same, low severity problem

99273              Same, moderate severity problem

99274              Same, moderate to high severity problem

99275              Same, high severity problem

99341        Home visit, new patient, low severity problem, 20 min.

99342              Same, moderate severity problem, 30 min.

99343              Same, moderate to high severity problem, 45 min.

99344              Same, high severity problem, 60 min.

99345              Same, patient unstable or significant new problem requiring immediate physician attention, 75 min.

93347        Home visit, established patient, self-limited or minor problem, 15 min.

99348              Same, low to moderate problem, 25 min.

99349              Same, moderate to high problem, 40 min.

99350              Same, patient unstable or significant new problem requiring immediate physician attention, 60 min.

99354        Prolonged physician services in office or other outpatient setting, with direct patient contact, first hour (use in conjunction with codes 99201-99215, 99241-99245, 99301-99350)

99355              Same, each additional 30 min.

99356        Prolonged services in inpatient setting, first hour (use in conjunction with 99221-99233, 99251-99255, 99261-99263)

99357              Same, each additional 30 min.

99358        Prolonged services in office or other outpatient setting, without direct patient contact, first hour

99359              Same, each additional 30 min.

-25             Modifier, significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service

99361        Team conferences by physician with interdisciplinary team or representatives of community agencies to coordinate activities of patient care (patient not present), 30 min.

99362              Same, 60 min.

99371        Telephone calls to patient (e.g., to report on tests or lab results, to clarify or alter previous instructions, to integrate new information from other health professionals into medical treatment plan, or to adjust therapies) or for consultation on medical management or for coordinating medical management with other health care professionals, simple or brief

99372              Same, intermediate

99373              Same, complex or lengthy

99374        Care plan oversight services requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports and related lab studies, communications, integration of new information into treatment plan, and/or adjustment of medical therapy, patient under care of home health agency, 15-29 min.

99375              Same, 30 min. or more

99377        Care plan oversight services, patient under care of hospice, 15-29 min.

99378              Same, 30 min. or more

99379        Care plan oversight, patient in a nursing facility, 15-29 min.

99380              Same, 30 min. or more

99381        Initial comprehensive preventive medicine, new patient, infant under 1

99382              Same, ages 1-4

99383              Same, ages 5-11

99384              Same, ages 12-17

99385              Same, ages 18-39

99391        Periodic comprehensive preventive medicine, established patient, infant under 1

99392              Same, ages 1-4

99393              Same, ages 5-11

99394              Same, ages 12-17

99395              Same, ages 18-39

99401        Preventive medicine counseling and/or risk factor reduction provided to an individual as a separate encounter and should address issues such as family problems, diet and exercise, substance abuse, injury prevention, and diagnostic and lab results, 15 min.  Not for reporting counseling or risk factor reduction provided to patients with symptoms or established illnesses.

99402              Same, 30 min.

99403              Same, 45 min.

99404              Same, 60 min.

99411        Preventive medicine counseling and/or risk factor reduction provided to individuals in a group setting, 30 min.

99412              Same, 60 min.

99420        Administration and interpretation of health risk assessment instrument

99450        Basic life and/or disability evaluation services that includes measurement of height, weight, and blood pressure, completion of a medical history following a life insurance pro forma, collection of blood sample and/or urinalysis complying with “chain of custody” protocols; and completion of necessary documentation/certificates.

99455        Work related or medical disability evaluation services that includes completion of medical history commensurate with patient’s condition; performance of examination commensurate with patient’s condition; formulation of diagnosis; assess of capabilities and stability and calculation of impairment; development of future medical treatment plan; and completion of necessary documentation/certificates and report.

90801        Psychiatric diagnostic interview examination

90802        Interactive psychiatric diagnostic interview examination using play equipment, physical devices, language interpretation, or other communication mechanisms

90804        Individual psychotherapy, 20-30 min.

90805              Same, with medical evaluation and management

90806        Individual psychotherapy, 45-50 min.

90807              Same, with medical evaluation and management services

90808        Individual psychotherapy, 75-80 min.

90809              Same, with medical evaluation and management services

90810        Individual psychotherapy, interactive, using play equipment, or other mechanisms, 20-30 min.

90811              Same, with medical evaluation and management services

90812        Individual psychotherapy, interactive, 45-50 min.

90813              Same, with medical evaluation and management services

90814        Individual psychotherapy, interactive 75-80 min.

90815              Same, with medical evaluation and management services

90846        Family psychotherapy (without patient)

90847              Same (with patient)

90849        Multiple-family group psychotherapy

90857        Interactive group psychotherapy

90862        Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy

90885        Psychiatric evaluation of hospital records, other psychiatric reports, and psychometric and/or projective tests, and other accumulated data for medical diagnostic purposes

90887        Interpretation or explanation of results of psychiatric, other medical exams, or other accumulated data to family or other responsible persons, or advising them how to assist patient

90889        Preparation of reports on patient’s psychiatric status, history, treatment, or progress (other than for legal or consultative purposes) for other physicians, agencies, or insurance carriers

92506        Evaluation of speech, language, voice, communication, and/or auditory aural rehabilitation status

92551        Audiologic screening test, pure tone only

92552        Pure tone audiometry (threshold), air only

92553        Same, air and bone

96100        Psychological testing (including psychodiagnostic assessment of personality, psychopathology, emotionality, intellectual abilities, eg, WAIS-R, Rorschach, MMPI) with interpretation and report, one hour

96105        Assessment of aphasia (includes assessment of expressive and recpetive speech and  language function, language comprehension, speech production ability, reading, spelling, writing, eg, Boston Diagnostic Aphasia Examination) with interpretation and report, per hour

96110        Developmental testing, limited (eg, Developmental Screening Test II, Early Lanugage Milestone  Screen), with interpretation and report

96111              Same, extended (includes assessment of motor, language, social, adaptive, and/or cognitive functioning by standardized developmental instruments, eg, Bayley Scales of Infant Development) with interpretation and report, per hour

96115        Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, eg, acquired knowledge, attention, memory, visual spatial abilities, language functions, planning) with interpretation and report, per hour

96117       Neuropsychological testing battery (e.g., Halstead-Reita, Luria, WAIS-R) with interpretation and report, per hour

96150        Health and behavior assessment performed by nonphysician provider (health-focused clinical interviews, behavior observations) to identify psychological, behavioral, emotional, cognitive or social factors important to management of physical health problems, 15 min., initial assessment

96151              Same, re-assessment

96152        Health and behavior intervention performed by nonphysician provider to improve patient’s health and well-being using cognitive, behavioral, social, and/or psychophysiological procedures designed to ameliorate specific disease-related problems), individual, 15 min.

96153              Same, group (2 or more patients)

96154              Same, family (with the patient present)

96155              Same (without the patient present)

97802        Medical nutrition therapy performed by nonphysician provider; initial assessment and intervention, individual , face-to-face with patient, 15 minutes

97803              Same, re-assessment and intervention, individual, face-to-face, 15 minutes

97804              Same, group (2 or more individuals, 30 minutes

99050        Services requested after office hours

99052        Services requested between 10pm-8am

99054        Services requested on Sundays and holidays

99056        Services provided at request of patient in location other than physician’s office

99058        Office services provided on an emergency basis

99071        Educational supplies, such as books, tapes, and pamphlets provided to patient at cost to physician

99078        Physician educational services rendered to patients in group setting (e.g. obesity or diabetic instructions)

99080        Special reports such as insurance forms, more than conveyed in usual medical communications

99090        Analysis of clinical data stored in computers

99091        Collection and interpretation of physiologic data

99173        Screening test of visual acuity, quantitative, bilateral (must employ graduated visual acuity stimuli that allow a quantitative estimate of visual estimate of visual acuity – e.g., Snellen chart).  Other identifiable services unrelated to this screening test provided at the same time may be reported separately (e.g., preventive services).

A mother calls to discuss the possibility of her child having ADHD due to ongoing school problems and the fact that this diagnosis was raised by the teacher who said to see “your pediatrician” about it.  Mom is concerned, and the call lasts 35 minutes.

A mother brings her child with Down syndrome for a 12-month checkup. She is an established patient. In addition to a comprehensive and age-appropriate history and physical examination with anticipatory guidance, the physician discusses issues related to Down Syndrome. This counseling lasts 35 minutes.  Consultation reports from the cardiologist and the Individual Family Service Plan from the early intervention program are reviewed.  Family requests contact with another family with child with Down syndrome and seeks information about total communication for child to develop skills in sign language, speech, and audition.  The visit lasts 55 minutes.

99392 –  Periodic comprehensive preventive medicine services visit,established patient, age 1-4 years (1st 20 minutes) Link to V20.3

99214-255 – Office or other outpatient visit, level 4, established patient, appended with modifier –25 (next 35 minutes) Link to ICD9 code for Down Syndrome

36415  – Collection of venous blood by venipuncture

908876 – Interpretation or explanation of results.

1 Two of the medical home components — community and health system — sometimes can be supported through public and private grants, but seldom through fee-for-service or capitated payments.

2 Bradly J and Salus T (eds.) Coding for Pediatrics: A Manual for Pediatric Documentation and Reimbursement (8^th Edition). EIK Grove Village, IL: American Academy of Pediatrics, 2003.

3 Strickland B, McPherson M, Weissman G, van Dyck P, Huang Z, Newacheck P. Access to the Medical Home: Results of the National Survey of Children with Special Health Care Needs.  Forthcoming.

⁴ Medical Home Initiatives for Children with Special Needs Project Advisory Committee. The Medical Home. Pediatrics. Vol. 110, No. 1, 184-186, July 2002.

⁵ Modifier –25 is defined as a “significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.” As its definition indicates, it can only modify an evaluation and management (E/M) code.  Additionally, the E/M code to which it is appended must be both significant and separately identifiable from any other service provided on the same day.  Therefore, the E/M code that has been appended with the modifier –25 must meet all the documentation requirements as outlined in the CPT guidelines.  This means that the key components of history, physical examination, and medical decision making must be met and clearly documented.  Alternatively, if greater than 50% of the E/M service is spent in counseling or coordinating care, time becomes the “key” or controlling factor in selecting a code.  In such cases, both the time spent and the topics covered during the counseling session must be explicitly documented.  A good rule to follow in determining whether an E/M code is truly significant and separately identifiable would be to assess whether the service provided could justify the patient returning at a separate encounter on a different day of service.

⁶ 90887 does not require any face-to-face time.